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WI  200 

G891a 

1903 

Griinwald,  Ludwig.  ^ 

Atlas  and  epitome  of  diseases  of 
the  mouth . . . 


WI  200 
G891a 

CJrunvald,  Ludwig. 

Atlas  and  epitome  of  diseases  of 
the  nouth ... 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


SAUNDERS'  MEDICAL  HAND-ATLASES 

Atlas  and  Epitome  of  Internal  Medicine  and  Clinical  Diagnosis.  Bv  IJR  Chr. 
Jakob,  of  firlangen.  Edited,  with  additions  by  Augustus  A.  Kshner  M.  D.,  Profes- 
sor of  Clinical  Medicine  in  the  Philadelphia  Polyclinic.  With  179  colored  figures  on  68 
plates  and  259  P^g"  of  text.  (-'"th,  $3-00  net. 

"  Dr.  Jakob's  work  deserves  nothing  but  praise.     The  information  is  accurate  and  up  to 
present-day  requirements."— /fr//wA  Medkal  Journal. 

Atlas  of  Legal  Medicine.     By  Dr.  E.  von  Hofmann,  of  Vienna, 
tions,  by  Kkkuekick   Pkterson,  M.  D.,  Chief  of  Clinic,  Nervous 


Edited,  with  addi- 
Department,  College 

of  Pfivsicians  and  Surgeons,  New  York.     With  120  colored  figures  on  56  plates  and  193 

half-tone  illustrations.  <-'«''.  *3So  net. 

"  It  is  rare  indeed  that  so  large  a  series  of  illustrations  are  found  which  demonstrate  so 

well  and  so  accurately  the  conditions  which  they  are  supposed  to  represent.  —Boston 

Metiical  and  Surgical  Journal. 
Atlas  and  Epitome  of  Diseases  of  the  Larynx.    By  Dr.  L.  GRUJrorALD,  of  Munich. 

Edited,  with  additions,  by  Charles  P.  Grayson,  M.  D.,  Physician-in-Charge,   Ihroat 

and  Nose  Department,  Hospital  of  the   University  of  Pennsylvania.     « Jth  107  colored 

figures  on  44  plates,  25  text-illustrations,  and  103  pages  of  text.  Cloth,  52.50  net. 

"  Excels  everything  we  have  hitherto  seen  in  the  way  of  coloured  illustrations  of  diseases 

of  the  larynx."— British  Medical  Journal. 
AUas  and  Epitome  of  Operative  Surgery.    By  Dr.  O.  Zuckerkandl,  of  Vienna. 

J-yom  the  Second  Revised  and  Enlarged  German  Edition.     Edited,  with  additions,  by 

J.  Ch/ 

Surgery, 

Enlarge, 

"  It  may  be  said  that  few,  if  any,  books  of  this  description  are  so  (Comprehensive  in  their 

scope." — Philadelphia  Medical  Journal. 

Atlas  and  Epitome  of  Syphilis  and  the  Venereal  Diseases.  By  Prop.  Dr.  Franz 
Mracek,  of  Vienna,  p^dited,  with  additions,  by  L.  Bolton  Bangs,  M.  D.,  Professor 
of  Oenito-Urinary  Surgery,  University  and  Bellevue  Hospital  Medical  College,  New 
York.     With  71  colored  plates  and  122  pages  of  text.  Cloth,  $3.50  net. 

"A  glance  through  the  book  is  almost  like  actual  attendance  upon  a  famous  clinic." — 
Journal  of  the  American  Medical  Association. 

Atlas  and  Epitome  of  External  Diseases  of  the  Bye.  By  Dr.  O.  Haad,  of  Zurich. 
Edited,  with  additions,  by  G.  E.  UB  Sciiwkinitz,  M.  D.,  Professor  of  Ophthalmology 
in  the  University  of  Pennsylvania.  With  76  colored  illustrations  on  40  plates  and  228 
pages  of  text.  Cloth,  $3.00  net. 

"  The  work  is  excellently  suited  to  the  student  of  ophthalmolog)'  and  to  the  practising 
physician.  The  enviable  status  of  the  author  and  of  the  editor  guarantees  the  excellence 
of  the  work." — Midi^al  Record ,  New  York. 

Atlas  and  Epitome  of  Skin  Diseases.  By  Prof.  Dr.  Franz  Mracek,  of  Vienna. 
Edited,  with  additions,  by  Henry  W.  Stelwagon,  M.  D.,  Clinical  Professor  of  Derma- 
tology, Jefferson  Medical  College,  Philadelphia.  With  63  colored  plates,  39  half-tone 
illustrations,  and  200  pages  of  text.  Cloth,  I3.50  net. 

"  The  illustrations  are  very  well  executed,  and  the  coloring  remarkably  accurate  ;  they 
will  serve  as  substitutes  for  clinical  observation." — Medical  Record,  New  York. 

Atlas  and  Epitome  of  Special  Pathologic  Histology.  By  Dr.  H.  Durck,  of  Munich 
Edited,  with  additions,  by  LuDViG  Hektoen,  M.  D.,  Professor  of  Pathology,  Rush 
Medical  College,  Chicago.  In  Two  Parts.  Part  I. — Circulatory,  Respiratory,  and 
Gastro-intestinal  Tracts.  Part  II. — Liver,  Urinary  and  Sexual  Organs,  Nervous  Sys- 
tem, SIcin,  Muscles,  and  Bones.  With  243  colored  figures  on  122  plates,  and  350  pages 
of  text.  Per  part :    $3.00  net. 

"  The  work  maintains  the  high  standard  of  iw  predecessors.  The  plates  are  most 
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the  various  organs  concerned  and  the  changes  produced  by  disease." —  The  Lancet , London. 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents.  By  Dr.  Ed.  Golbbibwski.  of 
Berlin.  'I'ranslated  and  edited,  with  additions,  by  Pbarcb  Bailey.  M.  D.,  Attending 
Physician  to  the  Almshouse  and  Incurable  Hospitals,  New  York.  With  71  colored  fig- 
ures on  40  plates  ;  T43  text-illustrations :  549  pages  of  text.  Cloth,  1^4.00  net. 
"  This  volume  appeals  not  only  to  the  medical  student  and  the  practitioner,  but  to  the 
medico-legal  specialist  and  accident  insurance  companies  also." — New  Vork  Med.  Jour. 

Atlas  and  Epitome  of  Gynecology.  By  Dr.  O.  ScHAEPFBR.of  Heidelberg.  From  the 
Second  Revised  and  Enlarged  German  Edition.  Edited,  with  additions,  by  Richard 
C.  NoKKis,  A.  M.,  M.D.,  Gynecologist  to  the  Methodist  Episcopal  and  Philadelphia 
Hospitals.  With  207  colored  illustrations  on  90  plates,  65  text-illustrations,  and  308  pages 
°'  »ext-  $3.50  net. 

"  The  book  contains  much  valuable  material.  .  .  .  Rarely  have  we  see.?~3chji  valuable 
collection  of  gynecological  plates."-  Bulletin  o/Jo/:,.i  Hopkins  Uospitc-'^'^ m^    • 


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lATLAS  AND  EPITOME 

OF 

DISEASES  OF  THE  MOUTH 
PHARYNX,  AND  NOSE 

BY 

DR.  L.  GRUNWALD 

Of  Munich 


Secont)  B&itfon,  1Repise&  nnt>  Bnlarget) 

Authorized  Translation  from  the  German 


EDITED,    WITH    ADDITIONS,    BY 


JAMES  E.  NEWCOMB,  M.D. 

Instructor  in  Laryngology,  Cornell  University  Medical  College;    Attending  Laryn- 

gologist  to  the  Roosevelt  Hospital,  Out-Patient  Department,  and  to 

the  Demilt  Dispensary,  New  York  City 


With  102  Illustrations  on  42  Lithographic  Elates,  and 
41  Figures  in  the  Text 


PHILADELPHIA  AND  LONDON 

W,  B.  SAUNDERS  &  COMPANY 
J903 


Copyright,  1903,  by  W.  B.  SAUNDERS  &   COMPANY. 


Registered  at  Stationers'  Hall,  London,  England. 


ELCCTROTYPED  BY  DRESS  OF 

WeSTCOTT  k  THOMSON,  PHILAOA.  W.  B.  SAUNDERS  &  COMPANY- 


EDITOR'S   PREFACE. 


The  work  of  the  editor  has  consisted,  first,  in  a  careful 
comparison  of  the  translation  with  the  original  text,  and, 
second,  in  the  addition  of  such  notes  as  have  seemed  advis- 
able to  represent  certain  distinctively  American  views 
on  the  several  topics  discussed.  The  most  extensive  of 
these  notes  relates  to  the  use  of  the  active  principle  of 
the  suprarenal  bodies,  which  has  won  for  itself  a  perma- 
nent place  in  the  materia  medica  of  rhinology  and  laryn- 
gology. 

With  the  stimulus  of  a  deep  appreciation  of  the  valu- 
able services  to  this  special  department  of  medical  science 
of  the  distinguished  German  author  and  clinician,  it  has 
been  a  pleasurable  task  to  assist  in  bringing  them  to  the 
knowledge  of  a  wider  circle  of  readers  on  this  side  of  the 
Atlantic. 

J.  E.  N. 


25294 


PREFACE  TO  THE  SECOND   EDITION. 


The  present  second  edition  of  this  atlas  represents  a 
complete  remodeling  of"  the  first  edition.  In  accordance 
with  the  general  plan  of  the  nndertaking,  which  has  now 
attained  siicii  gigantic  proportions,  a  short  epitome  has 
been  added  to  the  explanatory  text  of  the  illustrations. 
As  in  the  case  of  the  Atlas  of  Diseases  of  the  Larynx, 
the  epitome  is  designed  to  assist  both  students  and  prac- 
tising physicians  to  obtain  a  clear  understanding  of  the 
more  difficult  departments  of  the  subject.  The  material 
is  therefore  subdivided  according  to  general  pathologic 
principles,  instead  of  strict  localization  by  special  regions, 
which  would  be  both  tedious  and  perplexing.  Snch  head- 
ings as  "  Diseases  of  the  Xasal  Septum,"  "  Diseases  of  the 
Soft  Palate,"  and  the  like  will  not  be  found  in  this 
volume,  and  this,  the  author  flatters  himself,  will  not  be 
regarded  as  a  disadvantage  by  the  unprejudiced  reader. 
His  aim  has  been  to  arouse  a  general  understanding  of 
pathologic  conditions.  The  technicand  the  clinical  details 
in  this  department  of  medicine  can  be  learned  only  on  the 
living  subject,  under  the  guidance  of  a  competent  teacher ; 
hence  in  the  matter  of  treatment  the  author  has  confined 
himself  to  a  few  hints  which  practical  experience  has 
shown  to  be  necessary,  and  which  will  perhaps  be  riot 
unwelcome  even  to  out-students  in  clinical  courses  and 
polyclinics.  A  few  very  common  and  important  surgical 
operations  have  been  described,  because  the  omission  of 
an  apparently  immaterial  detail  may  in  certain  cases 
render  the  operation  absolutely  worthless.  In  spite  of 
all  these  limitations,  an  attempt  has  been  made  to  give 
as  exhaustive  an  exposition  of  the  subject  as  possible. 

7 


8  PREFACE  TO   THE  SECOND  EDITION. 

Material  changes  will  also  be  found  in  tiie  atlas  itself. 
The  text,  in  addition  to  the  descriptions  of  the'plates,  con- 
tains, as  in  the  Atlas  on  the  Lnrynx,  complete  case  his- 
tories designed  to  supplement  the  text  of  the  epitome  by 
some  important  details.  The  plates  themselves  are  more 
numerous  than  in  the  last  edition,  and  the  earlier  ones 
have  been  worked  over  and. adapted  to  harmonize  with  the 
general  plan  of  the  work — a  plan  which  the  author 
believes  is  an  improvement  as  well  as  an  innovation. 

A  number  of  histologic  plates  have  been  added  as  ex- 
planatory aids.  Only  such  operations  and  instruments  as 
are  still  quite  unknown  will  be  found  illustrated  in  the 
text,  because  any  others  can  be  readily  found  in  instru- 
ment-makers' catalogues  and  similar  publications.  The 
newer  instruments  here  illustrated  are  from  the  firm  of 
Stiefenhofer,  of  Munich,  to  whom  the  author  is  also  in- 
debted for  the  use  of  a  number  of  other  cuts. 

The  pictures  were  prepared  partly  from  personal  sketches 
and  partly  from  life — most  of  them  by  the  artists,  Messrs. 
Fink  and  Hammerschmidt.  Thanks  are  due  to  these 
gentlemen  for  their  intelligent  manipulation  of  the  dif- 
ficult subject-matter,  as  well  as  to  the  publisher  for  his 
liberal  aid  in  furthering  the  success  of  the  work ;  and, 
finally,  to  the  lithographer,  Mr.  Reichhold,  for  his  con- 
scientious and  artistic  work  in  preparing  the  plates. 

Special  thanks  are  also  due  to  Professor  v.  Bauer  for 
his  kindness  in  allowing  the  use  of  several  cases  from 
his  clinic,  and  to  Professor  May  for  his  obliging  help  in 
selecting  those  cases. 

The  Author. 


PREFACE  TO  THE  FIRST   EDITION. 


When  the  publisher  of  this  work  requested  me  to  con- 
tribute the  present  volume  to  his  collection  of  hand- 
atlases,  I  was  well  aware  of  the  difficulty  of  competing 
with  the  already  existing  excellent  works  on  this  subject. 
I  was  encouraged,  however,  by  the  consideration  that  the 
publisher's  idea  of  bringing  the  atlases  within  the  reach 
of  a  wide  circle  of  readers,  especially  students,  would  un- 
questionably bear  good  fruit.  Accordingly,  I  have  kept 
the  needs  of  students  in  view  by  selecting,  so  far  as  possi- 
ble, typical  cases  of  the  various  diseases,  and  omitting  rare 
conditions  and  curiosities,  the  description  of  which  more 
properly  falls  within  the  scope  of  larger  illustrated  works. 

My  chief  object  was  to  encourage  objective  instruction 
in  our  curriculum,  and  to  show  to  the  students  what  must 
be  observed  and  what  methods  are  to  be  employed  in 
observation.  The  subject-matter  of  the  text  has  been  ar- 
ranged with  this  end  in  view.  Just  as  an  expert  observer 
may  make  the  diagnosis  by  mere  inspection  of  the  illus- 
trations, so  the  accompanying  description  should  at  once 
bring  up  a  mental  picture  of  the  pathologic  condition  de- 
scribed. Accordingly,  the  illustrations  are  described  in 
the  text  in  exactly  the  same  way  as  a  practised  examiner 
would  demonstrate  the  objective  findings  to  his  class, 
allowing  the  student  to  draw  his  own  conclusions.  This, 
however,  could  be  carried  out  only  so  far  as  the  visible 
properties  of  the  condition  portrayed  supply  all  the  neces- 
sary data  for  a  diagnosis.  When  that  was  impossible,  the 
other  findings  required  for  diagnosis  were  included  in  the 
description.  It  is  impossible,  as  it  is  unnecessary,  to 
mention  all  the  pathologic  varieties,  and  I  have  confined 


10  PREFACE  TO   THE  FIRST  EDITION. 

myself  to  those  which  either  are  of  practical  importance 
or  in  which  tiie  signs  determinable  by  inspection  form  the 
most  prominent  features.  For  this  reason  I  have  included 
a  few  rare  clinical  conditions  that  occur  under  very  espe- 
cial circumstances  in  the  nose,  so  as  to  demonstrate  as 
clearly  as  possible  the  question  of  perspective,  which  is  so 
very  important  in  this  branch  of  our  subject. 

As  regards  the  preparation  of  the  illustrations,  the  ma- 
jority of  them  were  painted  by  myself;  two  were  photo- 
graphed from  nature ;  one  was  taken  from  the  well- 
known  atlas  by  Luschka ;  and  one  was  prepared  with 
the  kind  permission  of  Dr.  Mikulicz.  Most  of  the  pict- 
ures were  drawn  directly  from  nature;  a  few  had  to  be 
copied  from  older  drawings  and  sketches. 

The  Author. 


CONTENTS. 


.     PACE 

Pkeliminary  Kemarks  on  Anatomy  and  Physiology  ....  1 

GENERAL  REMARKS  ON  PATHOLOGY. 

Causes 19 

Symptoms 23 

Examination       31 

Treatment 39 

SPECIAL  PATHOLOGY  AND  TREATMENT. 

Acute  Inflammations      54 

Simple  Acute  Catarrh 54 

Superficial  Forms      55 

Exudative  Inflammations 59 

Diphtheria      60 

Interstitial  Inflanmiation 63 

Erysipelas 63 

Gangrene 69 

Symptomatic  Combined  Forms 70 

The  Acute  Exanthemata 70 

Stomatitis 73 

Influenza      74 

Typhoid  Fever 75 

Herpes 76 

Syphilis 77 

Chronic  Inflammations 80 

Diffuse  Forms 91 

Focal  Diseases 91 

Nasopharynx 91 

Nasal  Passages 93 

Diseases  of  the  Antrum  of  Highmore 96 

11 


12  CONTENTS. 

Chroftic  Inflammations  {Continued) :  page 

Diseases  of  tlie  Ktlimoid  Cells 104 

Disesises  of  the  Sphenoid  Sinus 109 

Diseases  of  the  Frontal  Sinus      Ill 

Symptomatic  Persistent  Inflammations 119 

Syphilis 119 

Glanders 125 

Tuberculosis 120 

Leprosy 129 

Scleroma 131 

Actinomycosis 132 

Inflammatory  Diseases  and   Hyperplasias  of  the   Lym- 
phatic Ring 134 

Mycoses 162 

Neoplasms 164 

Homologous  Neoplasms 164 

Heterologous  Neoplasms 173 

Congenital  Neoplasms 177 

Appearances  Observed  in  the  Upper  Mucous  Membranes 

in  General  Diseases 181 

Diseases  of  the  Nerves  and  Muscles 183 

Motor  Disturbances 183 

Hypokinetic  Disturbances 183 

Hyperkinetic  Disturbances  ....        185 

Sen.sory  Disturbances 186 

Disturbances  of  Special  Sense 189 

Vasomotor  and  Secretory  Disturbances 191 

Eeflex  and  Remote  Symptoms        191 

Traumatic,  Mechanical,  Chemical,  and  Thermic  Injuries  .  197 

Foreign  Bodies 201 

Malformations 205 

Index 213 


DESCRIPTION    OF   PLATES. 


MACROSCOPIC  PLATES. 

Plates  1-2.— External  Diseases  of  the  Mouth. 

Plate    1.— Fig.  1.— Scurvy. 

Fig.  2.— Carcinoma  (epitlielioma)  of  the  lip. 
Plate    2.— Fig.  1.— Condyloma  latum  labii  (mucous  patch). 

Fig.  2. — Aphthous  tubercular  ulcer.' 

Plates  3-5.— Internal  Diseases  of  the  Mouth. 

Plate    3. — Fig.  1.— Catarrhal  stomatitis. 

Fig.  2. — Mercurial  stomatitis. 
Plate    4. — Fig.  1. — Tubercular  ulcer  of  the  mouth. 

Fig.  2. — Pyorrhoea  alveolai-is. 
Plate    5.— Fig.  1.— Epulis. 

Fig.  2. — Aphthous  stomatitis. 

Plate  5.— Fig.  3.— Plate  7.    Diseases  of  the  Tongue. 

Fig.  3. — Lingua  nigra  (nigrities  linguae). 
Plate    6. — Fig.  1. — Leukoplakia  linguse. 

Fig.  2. — Lingua  geographica. 
Plate    7.— Fig.  1. — Ulcerative  gumma  of  the  tongue. 

Fig.  2. — Carcinoma  (epithelioma)  of  the  tongue. 

Fig.  3. — Hypertrophy  of  the  lingual  tonsil. 

Plates  8-12.— Diseases  of  the  Palatal  Tonsils  and  Fauces. 

Plate    8. — Fig.  1. — Acute  lacunar  angina  (lacunar  tonsillitis). 

Fig.  2. — Benign  fibrinous  angina. 

Fig.  3. — Faucial  diphtheria. 
Plate    9. — Fig.  1. — Supratonsillar  abscess. 

Fig.  2. — Pharyngeal  erysipelas. 
Plate  10.— Fig.  1.— Maceration  of  the  tonsillar  epithelium. 

Fig.  2. — Mucous  patches. 

Fig.  3.— Tertiary  syphilitic  ulcer  of  the  tonsil. 

13 


14  DESCRIPTION'   OF  PLATES, 

Plate  11. — Fig.  1. — Tonsillar  bypertiophy. 

Fig.  2. — Priiiiaiy  sarcoma  of  the  tonsil. 
Plate  12.  —Fig.  1. — Carcinoma  of  the  tonsil. 

Fig.  2. — Neoplasm — probably  benign. 

Plates  13-17.— Diseases  of  the  Palate  and  Uvula. 

Plate  13. — Fig.  1. — Typhoid  ulcei-s. 

Fig.  2. — Pharyngeal  herpes. 
Plate  14. — Fig.  1.  —Pharyngeal  thrush. 

Fig.  2. — Bednar's  aphthous  stomatitis. 

Fig.  3. — Pharyngomycosis  leptothricia. 
Plate  15. — Fig.  1. — Syphilitic  ulcer  of  the  soft  palate. 

Fig.  2. — Postsyphilitic  defects  and  scars. 
Plate  16. — Fig.  1. — Miliary  gummata. 

Fig.  2. — Pharyngeal  tuberculosis  resembling  lupus. 

Fig.  3. — Lepra  in  its  early  stage. 
Plate  17. — Fig.  1. — Scurvy.     The  case-history  and  description  of  this 
figure  will  be  found  opposite  Plate  1,  Fig.  1. 

Fig.  2. — Broad  syphilitic  papule. 

Fig.  3.     Tuberculosis  of  the  hard  palate. 

Plates  18-19.— Diseases  localized  on  the  Posterior  Wall  of  the 
Pharynx. 

Plate  18. — Fig.  1. — Pharyngitis  granulosa  et  lateralis  hypertrophica. 

Fig.  2. — Carcinoma  of  the  pharynx. 
Plate  19. — Fig.  1. — Ulcerating  gumma. 

Fig.  2. — Tertiary  syphilis. 

Fig.  3. — Cicatrized  syphilitic  ulcers. 

Plates  20-26. — Illustrations  of  the  Nasopharynx. 

Plate  20. — Fig.  1. — I.  Eustachian    tube   in   the   quiescent  state.      11. 
Eustachian  tube  during  deglutition. 

Fig.  2. — Hypertrophied  pharyngeal  tonsil. 

Fig.  3. — Adenoid  vegetations. 
Plate  21. — Fig.  1. — Lacunar  inflammation  of  the  pharyngeal  tonsils. 

Fig.  2. — Retronastil  phlegmon. 
Plate  22. — Fig.  1. — Localized  retronasal  catarrh  ( recessus  pharyngeus 
lateralis). 

Fig.  2. — Fetid  atrophic  rhinitis  or  ozena. 
Plate  23. — Fig.  1. — Sarcoma  of  the  nasopharynx. 

Fig.  2.— Eetronasal  gumma. 


DESCRIPTION  OF  PLATES.  15 

Plate  24. — Fig.  1. — Acute  .salpingitis. 

Fig.  2. — Acute  nasal  suppuration. 
Plate  25. — Fig.  1. — Syphilitic  ulcei-s  of  the  nasopharyngeal  vault. 

Fig.  2. — Residua  of  ulcerative  syphilis. 

Fig.  3. — Syphilitic  necrosis  of  the  vomer. 
Plate  2(5. — Fig.  1. — Papillary  hypertrophy  of  the  posterior  extremities 
of  the  inferior  turbinates. 

Fig.  2. — Retronasal  polyp. 

Fig.  3. — Fibroid  of  the  nasopharyngeal  space. 

Plates  27-30.— Rhinoscopic  Images. 

Plate  27. — Fig.  1. — Spine  and  deviation  of  the  nasal  septum. 

Fig.  2. — Suppurative  folliculitis  of  the  meatus  of  the  nose. 

Fig.  3. — Traumatic  erosion  of  the  wall  of  the  septum. 

Fig.  4. — Hypertrophy  of  the  mucous  membrane  of  the  sep- 
tum. 

Fig.  5.— Lateral  fold. 
Plate  28. — Fig.  1.— Nasal  polypi. 

Fig.  2.— Hypertrophy  of  the  middle  turbinate. 

Fig.  3.— Entrance  to  the  frontal  sinus. 

Fig.  4. — Left  sphenoid  sinus. 
Plate  29. — Fig.  1. — Appearance  after  partial  removal  of  both  middle 
turbinates. 

Fig.  2. — Circumscribed  catan-h  of  the  middle  meatus. 

Fig.  3.— Ozena. 
Plate  30. — Fig.  L — Tuberculosis  of  the  nares. 

Fig.  2. — Papilloma  of  the  septum. 

Fig.  3. — Tertiary  syphilitic  ulcers. 

Fig.  4. — Fibrinous  rhinitis. 

MICROSCOPIC  PLATES. 

Plate  3L — Fig.  L — Sagittal   section    of    the   hyperplastic   pharyngeal 
tonsil  from  a  child. 
Fig.  2. — The  same  tumor  from  an  adult. 
Fig.  3. — Frontal  section  of  a  pharyngeal  tonsil. 
Plate  32. — Fig.  L— Pharyngeal  bursa. 

Fig.  2. — Small,  soft,  pedunculated  tumor  growing  from  the 

upper  surface  of  one  of  the  palatal  tonsils. 
Fig.  3, — Juvenile  sarcoi-"  ■    ~ 


16  DESCRIPTION  OF  PLATES. 

Plate  33. — Fig.  1. — Section  of  smooth,  club-shaped  hypertrophy  of  the 
anterior  extremity  of  the  inferior  turl)inate. 
Fig.  2. — Combination  i)icture  from  a  nuicoiis  poly[). 
Plate  34. — Pale-red,  slightly  bosselated  tumor  on  the  anterior  extremity 

of  the  inferior  turbinate. 
Plate  35. — Fig.  1. — Part  of  a  section   of  a  pale-red   tumor  from  the 
anterior  extremity  of  the  middle  turbinate. 
Fig.  2. — Part  of  a  cauliflower  tumor  from  the  middle  turbi- 
nate. 
Plate  36. — Fig.  1. — Gummatous  and  diffuse  syphilitic  hyperplasia. 

PHg.  2. — Tuberculous  tumor  of  the  septum. 
Plate  37. — Fig.  1. — Bone  cyst  in  the  middle  turbinate. 

Fig.  2. — Ulceration   of    middle   turbinate   from   a   case   of 
antrum  disease. 
Plate  38. — Fig.  1. — Superficial   ulcer  with  granulating  and   rarefying 
osteitis. 
Fig.  2. — Granulating,    hypei-plastic,   and   rarefying   osteitis 
underneath  an  ulcer  involving  the  entire  thick- 
ness of  the  mucous  membrane. 
Plate  39.— Edematous  fibroma  with  inflammatory  infiltrntion. 
Plate  40. — Slightly  lobulated,  dark-refl  tumor  from   the  anterior  ex- 
tremity of  an  inferior  turbinate. 
Plate  41. — Fig.  1. — Soft  papillaiy  fibroma  from  the  anterior  portion  of 
an  inferior  turbinate. 
Fig.  2.— Angiofibroma  from  the  anterior  extremity  of  an 
inferior  turbinate. 
Plate  42. — Angiosarcoma  of  the  nose. 


TahJ. 


<AKAsy> 


%  •♦ 


Fig.l. 


\ 


\ 


J.Uh.  Anst  F.  EeidUuild.  MUivrhen . 


PLATE  1. 

Fig.  1. — A  man,  thirty-four  years  of  age,  was  admitted  to  the  hos- 
pital in  a  wretched  stJite  of  health,  lie  had  endured  several  weeks 
of  hardship,  during  which  he  had  been  without  shelter.  On  the  day 
following  his  admission  hemorrhages  were  noticed  from  the  mouth,  and 
blood  was  found  in  the  urine  and  feces. 

The  oral  mucous  membi-ane  is  exceedingly  dry  and  somewhat  livid. 
The  gums  at  the  margin  of  the  teeth  are  swollen  and  present  a  whitish 
discoloration.  On  the  inner  surface  of  the  lower  lip  are  several 
ecchymoses  of  varying  extent,  and  a  hemorrhagic  vesicle  the  size  of  a 
lentil.     The  skin  has  a  yellowish  tint. 

The  hemorrhages  extend  to  the  gums  in  the  upper  jaw  and  to  the 
hard  palate  (see  PLite  17,  Fig.  1),  where  they  are  quite  recent,  as 
evidenced  by  their  lighter  color  and  striated  appearance.  The  mar- 
gins of  the  lips  are  covered  with  desiccated,  hemorrhagic  scabs.  The 
surface  of  the  tongue  is  dark  gray  in  color  from  the  presence  of  dried 
blood.  These  acute  spontaneous  hemorrhages  point  to  dyscrasic  changes 
in  the  blood.  The  hemorrhages  in  the  mucous  membi-ane  are  especially 
characteristic  of 

Scurvy. 

Fig.  2.— a  man,  sixty-three  yeai-s  of  age,  has  noticed  a  wart  on  the 
lower  lip  for  the  past  six  months.  Recently  he  noticed  that  the  wart 
occasionally  discharged  and  crusts  were  beginning  to  form. 

On  the  vermilion  of  tlie  lower  lip,  a  little  to  the  left  of  the  median 
line,  there  is  an  oval,  dark-red  elevation  about  half  the  size  of  a  lentil, 
with  raised  edges  and  a  central  depression  of  a  somewhat  lighter  color. 

On  palpation  the  tumor  is  found  to  be  hard  and  not  sharply  defined 
from  the  surrounding  tissues.  No  glands  can  be  felt  either  under  the 
chin  or  at  the  angle  of  the  jaw.  The  patient's  parents  died  rather 
suddenly  of  some  unknown  disease  in  extreme  old  age. 

The  patient's  age,  the  appearance  and  seat  of  the  neoplasm,  which 
suggests  rather  an  infiltration  than  a  true  tumor,  and  its  tendency  to 
degeneration,  as  evidenced  by  the  central  depression,  leave  no  doubt  as 
to  the  diagnosis,  which  is 

Carcinoma  (Epithelioma)  of  tlie  Lip. 


PLATE  2. 

Fig.  1. — A  strong,  healthy  man,  thirty-six  yeare  of  age,  presents 
himself  for  examination  on  account  of  a  small  ulcer  on  the  upper  lip, 
which  made  its  appearance  about  two  weeks  ago. 

Near  the  inner  boi-der  of  tlie  upper  lip,  a  little  to  the  left  of  the 
median  line,  is  a  flat  ulcer  the  size  of  a  lentil,  covered  with  a  yellowish 
exudate  and  surrounded  by  a  narrow,  red  areola.  Tlie  surrounding 
mucous  membrane  is  somewhat  tumefied  and  colored  bluish-white.  An 
area  of  similar  discoloration  is  found  on  the  riglit  side  and  somewhat 
moi*e  internally. 

The  discoloi-ation,  combined  with  the  subacute  course,  at  once 
arouses  suspicion  of  syphilis.  The  patient,  it  is  true,  "  knows  of  no 
infection";  on  the  other  hand,  inspection  of  the  skin  yields  positive 
information,  for  on  the  bi-east  there  are  a  few  coppery  macules  the  size 
of  the  head  of  a  pin  that  do  not  quite  disappear  on  pressure,  and  the 
diagnosis  of 

Condyloma  Latum  Labii  (Mucous  Patch) 

is  assui-ed. 

Fig.  2. — An  obstinate  inflammatory  condition  has  developed  in  the 
course  of  the  last  two  months  at  the  right  angle  of  the  mouth  of  a  man, 
twenty-five  yeare  of  age,  suffering  from  tubercular  apical  catarrh.  At 
the  labial  junction  is  a  somewhat  reddened,  slightly  depressed  area, 
surrounded  by  irregulai-,  bluish-white,  raised  edges.  There  is  no  pain. 
No  glandidar  enlargement  can  be  found,  either  under  tlie  jaw  or  in  the 
neck  or  above  the  elbow.     The  diagnosis  is 

Aphthous  Tubercular  Ulcer, 

and  although  no  tubercle  bacilli  can  be  found,  it  is  confirmed  by  the 
slowly  progressing,  non-inflammatory  enlargement,  notwithstanding  the 
administration  of  potassium  iodid. 


p^' 


i 


o 


Figl. 


Fig.  2. 


LUh-  An.\t  t:  Feietllwtd  Miuirlun. 


Tab.X 


Fig.l. 


/ 


'  K 


l.Uh,  Anal  F.  Rjeichliold  Mti/ichen. 


PLATE  3. 

Fig.  1. — The  gums  of  the  lower  jaw  are  somewhat  swollen,  livid  in 
color,  with  a  superticial  whitish  sheen.  U'he  border  next  to  the  teeth 
is  distinctly  reddened,  and  in  places  presents  a  somewhat  whitish  dis- 
coloration.    We  have  before  us  the  appearances  of 

Catarrhal  Stomatitis, 

which  is  apt  to  follow  neglect  of  the  mouth,  excessive  smoking,  etc., 
and  occurs  with  especial  preference  in  febrile  diseases  and  as  the  initial 
stage  of  mercurial  salivation. 

The  edge  of  the  tongue,  which  is  thrust  forward  into  the  left  angle 
of  the  mouth,  is  somewhat  swollen,  and  at  about  the  middle  there  is  a 
superficial,  somewhat  irregular  ulcer,  covered  with  a  grayish  exudate, 
the  surrounding  mucous  membrane  showing  a  whitish  discoloration. 
It  is  a 

Decubital  Ulcer, 

produced  by  the  edge  of  the  tongue  rubbing  against  a  sharp  or  carious 
tooth.  The  whitish  discoloration  here,  as  well  as  in  the  gums,  is  to  be 
attributed  to  cloudy  swelling  of  the  epithelium. 

Fig.  2. — The  gums  of  the  lower  jaw  are  swollen,  livid,  and  separated 
from  the  teeth  by  a  vivid  red  border.  They  do  not  extend  as  high  as 
under  normal  conditions,  so  that  the  teeth  appear  lengthened.  Two 
uleei-s  are  seen  at  the  junction  with  the  muc(ms  membrane  of  the  lower 
lip  ;  and  two  others  on  the  lower  lip,  which  ha-s  been  turned  down. 
The  ulcers  are  flat,  with  rather  sharply  outlined  edges,  and  surrounded 
by  a  narrow  inflammatory  zone ;  the  flooi-s  of  the  ulcers  are  covered 
with  a  yellowish  exudate.  The  entire  picture  is  that  of  acute  catarrh, 
and  in  the  light  of  the  history  is  recognized  as 

Mercurial  Stomatitis. 

The  ulcere  are  to  be  interpreted  as  decubital  ulcers ;  those  at  the  edge 
of  the  gums  are  produced  by  the  caustic  irritation  of  the  secretion 
accumulated  tetween  the  folds  of  the  swollen  mucous  membrane,  while 
those  on  the  lower  lip  itself  are  to  be  attributed  chiefly  to  the  pressui-e 
of  the  teeth.  Ulcers  of  this  kind  are  seen  in  greatly  neglected  cases  or 
in  very  severe  mercurial  intoxication. 


PLATE  4. 

F^G,  1. — The  patient,  a  man  of  forty-one,  has  been  under  observation 
for  the  piist  three  and  one-half  years.  At  tii-st  he  had  ulcers  at  tlie 
right  angle  of  the  mouth  and  on  the  tongue,  wliieh  healed  after  repeated 
ciiUHtic  applications.  Later  he  developed  a  fistula  in  ano  and  chronic 
infilti'ation  of  the  posterior  wall  of  the  larynx.  Recently  he  had  .several 
slight  hemorrhages  from  the  lungs. 

Lungs :  Over  the  anterior  upj)er  portion  of  the  right  lung  there  is 
slight  impainnent  of  resonance,  with  accentuated  vesicular  breathing. 
Larynx :  Marked  infiltration  and  tumor  formation  in  the  pasterior  wall, 
in  the  right  ventricular  band,  and  in  the  left  true  vocal  cord. 

At  the  junction  of  the  lower  lip  with  the  gums  there  is  a  deep, 
grayish-green  ulcer,  with  lumpy,  thickened,  undermined  edges,  the 
immediate  surroundings  of  which  are  covered  by  isolated  yellowi.sh 
nodules  the  size  of  the  head  of  a  pin.  The  middle  of  the  right  half  of 
the  tongue  presents  a  smooth,  triangular  scar  with  greatly  retracted 
center. 

A  single  tubercle  bacillus  was  found  in  the  discharge  obtained  from 
the  ulcer;  but  even  without  the  finding  of  this  bacillus,  decisive  as  it 
is,  the  picture  itself,  and  especially  its  association  with  the  other  affec- 
tions, would  assure  the  diagnosis  of 

Tubercular  Ulcer  of  the  Mouth. 

Fig.  2. — The  patient,  a  young  lady  of  thirty-two  years,  is  reduced 
in  health  owing  to  repeated  attacks  of  pleurisy  with  efi'usion  ;  she  com- 
plains about  her  teeth,  which,  she  says,  are  becoming  loose. 

After  a  somewhat  purulent  exudate  has  been  removed  from  the 
gums  of  the  upper  jaw,  it  appeai-s  that  the  gums  are  enlarged,  espe- 
cially on  the  left  side,  the  swelling  becoming  more  distinct  toward  the 
molar  teeth,  with  the  fonnation  of  small,  rounded,  bluish-red  nodules 
encroaching  on  the  surfaces  of  the  teeth  and  the  interdental  spaces. 
The  gums  over  the  roots  of  the  teeth,  on  the  other  hand,  are  retracted 
upward,  so  that  in  the  canine  teeth,  for  instance,  half  of  the  root  is 
exposed.  The  teeth  themselves,  especially  the  canine  tooth,  show 
greenish-gray  discoloration  from  the  deposition  of  tartar.  This  condi- 
tion, referable  to  neglect  of  oral  hygiene  and  to  bodily  weakness,  is 
that  of 

Pyorrhoea  Alveolaris. 


Tab.4. 


Fig.1. 


Fiff.^. 


LUh.  Arist  t:  Hetc/.hold  Mnnrher 


Tab.  J). 


FiB.l. 


Fig.2. 


Fig.3. 


uh.  Anst  K  ReidUioLd.  iiiinchen 


PLATE  5. 

Fig.  1. — In  the  coui-se  of  the  past  year  the  second  of  the  upper 
molars  of  a  woman,  thirty-eight  yeiirs  of  age,  has  gradually  come  away 
in  fragments,  and  its  site  is  now  occupied  by  a  movable  tumor.  At  the 
angle  of  the  mouth,  which  is  exposed  by  means  of  retractore  as  far  as 
the  outer  side  of  the  fii-st  bicuspid,  a  bright-red  oval  tumor  about  the 
size  of  a  hazel-nut  is  seen  projecting  beyond  the  line  of  the  teeth,  and 
apparently  growing  from  the  gums.  The  boixier  is  smooth  and  rounded, 
the  inner  surface  is  depressed,  and  the  inner  edge  of  the  border,  as  well 
as  the  floor  of  the  depression,  are  somewhat  uneven.  Above  the  tumor, 
and  corresponding  with  the  line  of  the  second  molar,  which  is  con- 
cealed, is  a  small  fragment  of  bone.  On  palpation  the  latter  is  found 
to  be  movable.     The  tumor  is  known  as  an 

Epulis. 

The  name  does  not  explain  its  nature.  To  arrive  at  a  true  diagnosis 
the  clinical  conditions,  the  subsequent  course  after  removal  of  the 
tumor,  microscopic  examination,  and  the  general  condition  of  the 
patient  must  be  taken  into  considei-ation.  In  the  present  case  it  turned 
out  that  the  tumor  was  merely  a  periodontal  proliferation  occurring 
over  a  tooth  with  a  diseased  root. 

Fig.  2. — The  child's  mouth  presents  on  the  tongue,  especially  at  the 
margin,  on  the  hard  and  soft  palates,  and  on  the  buccal  mucous  mem- 
brane of  the  left  side,  a  number  of  dirty  yellow,  flat  exudates,  ranging  in 
size  from  the  head  of  a  pin  to  a  small  lentil,  and  surrounded  each  by  a 
narrow,  red  areola.  The  appearance,  the  peculiar  reaction  indicated 
by  the  inflanmiatory  areola,  and  the  irregular  distribution  characterize 
the  condition  as 

Aphthous  Stomatitis, 

an  infection  that  is  not  infrequent  during  childhood  when  the  mouth 
is  neglected,  and  is  probably  of  a  mycotic  nature. 

Fk;.  3. — On  casual  inspection  of  the  tongue  of  a  patient  in  middle 
life  its  peculiar  coloration  was  noted. 

The  entire  base  of  the  tongue  is  a  deep  grayish-brown.  On  the  sur- 
face and  toward  the  edges  are  a  number  of  patches  ranging  in  color 
from  light  brown  to  black,  and  resembling  bunches  of  hair,  which  on 
palpation  are  found  to  consist  of  a  mass  of  short,  thick  threads.  This 
peculiar  pictui-e,  which  is  designated 

Lingua  Nigra  (Nigrities  Linguae), 

is  produced  by  hypertrophic  comification,  with  pigmentary  degenera- 
tion of  the  filiform  papUlae. 


PLATE  6. 

Fig.  1. — From  time  to  time  the  patient,  a  gentleman  forty-two  years 
of  age,  has  attacks  of  difficult  mastication.  The  attacks  last  several 
weeks,  and  consist  in  slight  burning  of  the  tongue,  a  marked  feeling 
of  dryness,  and  a  pjvsty  taste.  The  upper  surface  of  the  tongue  and  the 
left  margin  are  occupied  by  a  number  of  bluish-white  msicules,  some 
of  which,  especially  near  the  edge,  allow  the  vermilion  of  the  tongue  to 
shine  through.  Further  back  are  two  small,  yellowish-brown,  flat 
deposits  within  similar  whitish  circles. 

The  patient  states  that  the  patches,  which  frequently  vaiy  in  extent, 
have  existed  for  a  number  of  yeai-s.  The  patient  had  syphilis  in  his 
youth  and  smokes  a  good  deal ;  he  also  suffers  greatly  from  nasopharyn- 
geal catarrh.  The  white  patches  are  produced  by  homy  changes  and 
desquamation  of  the  epithelium ;  the  brownish  patches  are  due  to 
advanced  horny  change  with  accumulation  of  pigment.  The  disease 
is  known  as 

Leucoplakia  Linguae, 
or  psoriasis  buccalis. 

Fig.  2. — A  boy,  fifteen  years  of  age,  has  observed  the  appearance  of 
patches  on  his  tongue  since  earliest  youth.  They  have  never  produced 
any  subjective  symptoms.  The  patches  vary,  both  as  to  seat  and  shape, 
and  sometimes  disappear  for  a  time.  The  tongue  is  travei-sed  by 
numerous  longitudinal  and  transverse  furrows  and  by  yellowish-white 
bands  which  intersect  in  such  a  way  as  to  form  a  great  variety  of 
figures.     The  true  mucous  membrane  is  of  a  bluish-red  color. 

We  have  to  deal  here  with  so-called 

Lingua  Geographica. 

The  furrows  are  congenital  (lingua  diasecata). 


Tab.6. 


0^ 


Fig.l. 


-U-Uf^ 


K 


Fig.^-  Litft-Anst/-:  Reichhnld  Miinchen. 


Tab.  7. 


Fig.J. 


Fi(f.2. 


PLATE   7. 

Fig.  1. — A  woman,  forty  years  of  age,  complains  of  increasing  diffi- 
culty in  speaking  and  chewing,  caused  by  a  swelling  of  the  tongue, 
which  has  developed  during  the  past  eight  weeks.  Recently  pain  was 
added  to  the  other  symptoms. 

The  right  half  of  the  tongue  is  swollen  in  front ;  the  posterior  half 
es^ieciaily  so,  and  thickened,  forming  several  ridges,  superimposed  like 
terraces.  At  the  base  of  the  tongue,  on  the  left  side,  there  is  a  slight 
swelling  surrounding  a  deep,  punched-out  ulcer  about  the  size  of  a 
lentil,  with  ncxiular,  overhanging,  somewhat  wavy  edges. 

The  sinuouii  outline  of  the  sore  strongly  suggests  a  tuberculous  ulcer, 
but  this  is  not  borne  out  by  the  subacute  course  of  the  extraoixlinary 
tumor-like  swelling,  bounded  by  the  median  line  of  tlie  tongue.  The 
course  is  also  too  rapid  for  malignant  neoplasm  ;  there  is  nothing  left 
but  syphilis.  As  a  matter  of  fact,  the  ulcer  soon  cleared  up  on  the 
exhibition  of  potassium  iodid,  and  the  swelling  partially  subsided,  so 
that  the  provisional  diagnosis  of 

Ulcerative  Gumma  of  the  Tongue 

was  amply  confirmed. 

Fig.  2. — A  man,  sixty-two  years  of  age,  has  noticed  a  small  wart  on 
his  tongue  for  some  time.  During  the  past  three  months  it  increased 
rapidly  in  size,  and  at  the  present  time  it  tends  to  bleed  easily,  and 
occasionally  gives  him  some  pain.  On  the  edge  of  the  right  half  of  the 
tongue  there  is  a  tumor  the  size  of  a  walnut,  moderately  elevated,  of  a 
whitish-red  color,  and  with  a  rough,  nodular  surface,  not  sharply  defined 
from  the  surrounding  normal  tissues.  The  picture  at  once  arouses  a 
suspicion  of  malignancy — in  fact,  it  is  easily  recognized  as  • 
Carcinoma  (Epithelioma)  of  the  Tongue. 

The  history  bcai-s  out  this  diagnosis,  and,  lastly,  a  few  hard  glands 
about  the  size  of  peas  are  found  in  the  angle  of  the  right  jaw. 

Fig.  3. — Attacks  of  irritative  cough  and  the  feeling  of  a  foreign 
body  in  the  throat  are  the  distressing  symptoms  complained  of  for 
several  yeare  by  a  man  thirty-five  years  of  age.  They  have  driven  him 
from  one  health  resort  to  another,  until  finally  he  is  beginning  to  fear 
that  he  has  a  cancer.  Nothing  unusual  is  found  in  the  nose,  naso- 
pharynx, and  throat,  except  a  slight  thickening  of  the  fauces.  Per- 
haps the  larynx  will  furnish  an  explanation.  The  illustration  shows 
an  (inverted)  image  of  the  posterior  parts  of  the  tongue  and  larynx; 
of  the  lower  structures,  the  commissure  of  the  vocal  cords  and  the 
epiglottis  are  visible.  The  latter  is  covered  by  a  massive  tumor  about 
the  size  of  a  hazel-nut,  marked  by  numerous  notches  and  surrounded  by 
wavy  edges  growing  from  the  base  of  the  tongue  behind  the  circum- 
vallate  papillae.  The  position  and  structure  of  the  tumor  are  charac- 
teristic of 

Hypertrophy  of  the  Lingual  Tonsil. 

That  this  small  tumor  is  enough  to  prwluce  the  symptoms  is 
clearly  shown  when  the  various  portions  of  the  throat  are  successively 
examined  with  a  probe  without  any  particular  objections  on  the  part  of 
the  patient,  whereas  the  slightest  application  of  the  instrument  to  the 
tumor  is  immediately  followed  by  a  violent  fit  of  coughing. 


PLATE  8. 

Fig.  1.— Headache,  depression,  lever  up  to  39°  C.  (102.2°  F.)  were  the 
secondary  symptoms  iu  an  attack  of  acute  i)ain  in  the  throat  with  great 
difficulty  in  swallowing  and  speaking.     The  pain  radiated  to  the  ears. 

Iu  the  pharynx  the  velum  is  slightly  reddened ;  the  uvula  still  more 
so  and  slightly  edematous;  both  tonsils  are  greatly  swollen  and  con- 
gested, and  covered  with  radiating  masses  of  yellowish-white  exudate, 
forming  a  continuous  pattern  ;  the  fauces  and  the  posterior  wall  of  the 
pharynx  are  not  involved.     It  is  the  typical  picture  of  an  ordinary 

Acute  Lacunar  Angina  (Lacunar  Tonsillitis). 

[In  this  connection  reference  may  be  made  to  an  ulceromembranous  form 
of  tonsillitis  due  to  the  bacillus  of  Vincent.  It  may  be  confined  to  the  tonsils 
or  appear  on  the  cheeks,  tongue,  and  gums.  It  generally  assumes  a  chan- 
croidal aspect,  having  a  worm-eaten  floor,  but  with  its  edge  on  a  level  with  or 
slightly  above  the  tonsillar  surface.  Except  for  the  necrotic  floor,  the  ulcer 
has  a  '•  puuehed-out "  appearance.  At  first  the  area  involved  seems  to  be  cov- 
ered with  a  false  membrane,  but  after  thirty-six  hours  a  swab  applied  against 
It  apparently  penetrates  it  and  enters  a  cavity.  The  color  of  the  area  mav  be 
yellowish,  greenish-gray,  or  a  dirty  light-brown.  As  a  rule,  the  submaxillary 
glands  are  enlarged— more  rarely  the  cervical.  The  enlargement  is  painle.'-s, 
and  remains  tur  some  time  after  the  ulcer  has  healed. 

As  a  rule,  there  are  no  constitutional  symptoms,  though  there  may  be  a 
mild  fever.  The  ton.sillar  ulceration  alone  rarely  causes  any  fetor  of  the 
breath,  but  if  the  lesion  spreads  to  the  other  sites  named,  fetor'appears.  The 
disease  is  not  dangerous,  but  calls  for  differentiation  from  lacunar  tonsillitis, 
diphtheria,  and  tonsillar  chancre. 

From  confluent  lacunar  tonsillitis  it  is  distinguished  by  the  absence  or 
mild  degree  of  constitutional  symptoms,  and  by  the  superficial" character  of  the 
lesion  in  the  tonsillitis.  The  two  conditions  may  coexist ;  from  diphtheria  it 
is  distinguished  by  the  culture-test  alone.  In  diphtheria  a  smear-test  is  unre- 
liable, but  in  ulceromembranous  tonsillitis  it  is  more  reliable  than  the  cul- 
ture, because  up  to  the  present  time  no  medium  has  been  found  for  the  growth 
of  the  bacillus  of  Vincent  in  pure,  uncontaminated  form  ;  from  syphilis  the 
smear-test  will  suffice  to  make  a  differentiation  This  test  is  here  most  impor- 
tant, for  we  do  not  wish  to  submit  a  patient  w  th  a  simple  tonsillitis  to  all  the 
annoyances  and  possible  dangers,  under  the  circumstances,  of  a  mercurial 
treatment.  If  syphilis  and  the  ulceromembranous  lesion  coexist,  we  should 
treat  the  latter  first. 

In  a  recent  paper,'  Vincent  makes  two  forms  of  the  affection :  (1)  a  diph- 
theroid, containing  a  characteristic  fusiform  bacillus  alone  ;  (2)  an  ulcero- 
membranous, containing  both  bacilli  and  spirilla.  Herman  and  Hobel* 
describe  the  former  as  about  twice  as  long  as  the  Klebs-Lofflcr  bacillus, 
needle-like,  and  somewhat  pointed  at  the  ends.  They  may  be  arranged  at  an 
acute  angle  or  be  irregularly  scattered  over  the  field.  The  spirilla  are  long  and 
cork-screw-like,  with  wide  curves.  Herman  and  Sobel  advance  the  following 
arguments  in  favor  of  the  specific  character  of  the  organism  :  (1)  Its  uniform 
presence  in  the  disease  in  very  large  numbers  or  nearly  pure  culture.  (V)  Its 
gradual  disappearance  during  the  process  of  healing  of  the  ulceration  and 
rapid  di.sappearance  when  the  process  is  ended.  (8)  The  presence  of  so  few 
other  micro-organisms.  (4)  The  occurrence  of  instances  in  which  the  disease 
has  been  transmitted  from  one  patient  to  another.  For  treatment  they  advise 
daily  applications  of  silver  nitrate  (8  to  5  per  cent.)  or  of  Lugol's  solution.  The 
latter  is  preferable  to,  but  more  painful  than,  the  former.  The  application  of 
a  saturated  aqueous  solution  of  methylen  blue  is  also  advised.— Ed.] 

Fig.  2. — This  patient,  a  man  twenty-two  years  of  age,  complained  of 
the  same  symptoms  as  the  last  patient,  except  that  the  pain  was  present 
only  on  the  right  side. 

1  Bull,  lie  la  Soe.  Med.  des  HSp.  de  Paris,  Feb.  1,  and  Mar.  23, 1901. 
"  New  York  Medical  Jour.,  Dec.  7,  1901. 


PLATE  8  (Continued). 

Accordiugly  we  find  the  right  side  of  the  pharynx  greatly  reddened, 
and  the  tonsil  covered  by  large  and  small  masses  of  yellowish  exudate. 

The  exudate  can  be  removed  with  the  forceps  without  j)roducing  a 
hemorrhage  or  revealing  any  marked  destruction  of  tissue.  Tliis  agrees 
with  the  strictly  circumscribed  character  of  the  inlianimation,  which 
involves  only  the  tonsil  and  shows  that  the  condition  is  not  a  necrotic, 
diphtheritic  process,  but  merely  a  coagulation  necrosis  confined  to  the 
epithelial  layer.    The  diagnosis  is 

Benign  Fibrinous  Angina. 

It  is  worth  noting  that  just  before  the  infiammation  subsided  similar 
phenomena  appeared  on  the  left  side. 

Fig.  3.— This  case  is  that  of  a  girl  twenty  years  of  age.  She  also 
presented  similar  general  and  local  symptoms.  The  temperature  was 
39.5°  C.  (103.1°  F.). 

The  greatly  swollen  and  club-shaped  uvula  is  the  most  conspicuous 
feature  in  the  pharynx,  which  is  of  a  deep  dark  red.  The  uvula,  the 
tonsils,  the  arches,  and  the  posterior  wall  are  covered  by  discrete  and 
confluent  yellowish-white  exudates  of  varying  thickness. 

An  attempt  to  remove  these  exudates  would  be  followed  by  hemor- 
rhage, but  this  sign  is  not  needed.  The  wide  distribution  of  the 
exudate,  extending  far  beyond  the  region  of  the  tonsils,  enables  us  to 
recognize  that  we  are  dealing  with 

Faucial  Diphtheria. 

[While  the  experience  of  each  clinician  may  enable  him  to  feel  positive 
that  a  given  faucial  exudation  is  or  is  not  true  diphtheria,  it  must  be  borne  in 
mind  that  the  culture-test  alone  can  decide.  Some  cases  resemblin<r  in  their 
appearance  and  clinical  rourse  an  ordinary  lacunar  tonsillitis  have  been 
shown  to  be  due  to  the  Klebs-Loffler  bacillus,  the  process  being  confined 
entirely  to  the  crypts.  The  obvious  lesson  is  the  familiar  one— to  isolate  every 
case  of  sore  throat  until  its  exact  nature  shall  be  accurately  determined.— Ed.] 


Tab.  8. 


SSb*. 


rC. 


Fig.l. 


Fig.J. 


Ei(f.2. 


LUh.  Anst  F.  ReUhhoUL.  Miiruhen,. 


TahJ). 


Fig.l. 


Fig.  2. 


l.ith:  Anst  /•:  HeicfiJivId,  Miinrhen. 


PLATE  9. 

Fig.  1. — A  man,  twenty-two  years  of  age,  has  had  severe  pain  in 
the  throat  for  the  past  three  days,  is  totally  unable  to  swallow,  and  has 
a  free  flow  of  saliva  which  he  expectoi-ates  with  great  difficulty.  He 
feels  very  much  depressed  and  complains  of  being  hot.  Temperature 
is  39.2°  C.  (102.6°  F.)  at  3  o'clock  in  the  afternoon.  The  left  side  of 
the  neck  is  somewhat  enlarged.  The  patient  is  barely  able  to  open 
the  mouth  (in  the  illustration  the  mouth  is  opened  somewhat  more 
widely  so  as  to  afford  a  better  view). 

The  left  half  of  the  soft  palate,  down  to  the  base,  is  intensely  swollen, 
and  the  tonsil  is  completely  obscured.  The  uvula,  which  is  completely 
deformed  by  the  swelling,  has  been  forced  over  toward  the  right.  The 
mucous  membrane  is  tense  and  bulging,  and  of  a  dark-red  color.  The 
bulging  is  greatest  in  the  region  of  the  upper  extremity  of  the  tonsil 
(not  visible),  where  the 

Supratonsillar  Abscess 

is  about  to  rupture. 

Fio.  2. — A  woman,  twenty-six  years  of  age,  was  taken  sick  three  days 
ago,  with  severe  general  symptoms,  headache,  and  pain  in  the  throat. 
The  temperature  has  been  as  high  as  39.5°  C.  (103.1°  F.),  but  on 
two  occasions  it  fell  immediately  to  37.8°  C.  (100.7°  F.)  and  37.6°  C. 
(100.4°  F). 

The  mouth  cannot  be  entirely  opened,  although  there  is  no  distinct 
interference  with  the  movement  of  the  jaws. 

In  the  region  of  the  left  tonsil  the  entire  soft  palate  bulges  outward, 
forming  a  distinct  tumor.  The  color  is  dark  red,  and  the  surface  dry 
and  glistening.  The  swelling  is  fairly  well  circumscribed  on  the  right, 
and  encroaches  on  the  uvula,  which  is  not  swollen  and  only  slightly 
reddened. 

The  absence  of  interference  with  the  movement  of  the  jaws  indi- 
cates that  the  infiltration  does  not  extend  deeply.  The  circumscribed 
character  of  the  tumor,  the  dry,  glistening  appearance  of  the  surface, 
indicating  superficial  tension,  and,  finally,  the  intermittent  fever,  at 
once  suggest  the  suspicion  of 

Pharyngeal   Erysipelas. 

No  pus  could  be  obtained  from  the  supratonsillar  fossa,  even  with 
the  probe,  and  on  the  following  day  the  temperature  became  normal. 
All  the  other  symptoms  rapidly  subsided  without  discharge  of  any  kind 
taking  place. 


PLATE  10. 

Fig.  1. — A  young  man,  seventeen  yeare  of  age,  lias  been  working 
as  an  apprentice  in  a  cigsir  factory  for  the  last  two  niontlis,  and  had  to 
swallow  a  good  deal  of  dust  in  the  course  of  his  work.  He  had  always 
suffered  more  or  less  from  pain  in  the  throat  and  copious  expectoration, 
but  under  the  influence  of  this  recent  hijury  the  dysphagia  greatly 
increased  and  he  began  to  suffer  from  a  scratchy  feeling  in  tiie  throat. 
As  a  child  he  was  sickly ;  his  father  died  of  pulmonary  disease  with 
asthma.     Infection  denied. 

The  patient  is  weak  and  anemic.  Lungs  and  heart  present  nothing 
abnonnal ;  no  fever.  Both  tonsils  are  somewhat  enlarged  and  covered 
with  a  grayish-white  exudate ;  there  are  no  signs  of  inflammation. 
The  tongue  is  thickly  coated.  The  posterior  extremities  of  both  lower 
turbinates  and  the  pharyngeal  tonsils  are  enlarged  and  covered  with 
copious  mucopurulent  exudate.  The  cervical  glands  on  both  sides  are 
swollen,  but  not  sensitive  to  the  touch.  It  may  be  added  that  the  con- 
dition shown  in  the  illustration  was  not  affected  by  two  weeks'  treat- 
ment, so  that  both  acute  infection  and  syphilis  could  be  excluded  with 
certainty. 

The  picture,  therefore,  which  is  very  unusual,  is  due  solely  to 

Maceration  of  the  Tonsillar  Epithelium. 

which  is  continuously  bathed  in  the  nasopharyngeal  pus ;  the  action 
of  the  latter  is  enhanced  by  the  patient's  poor  constitution  and  by  the 
recent  injuries  to  the  pharyngeal  organs. 

Fig.  2. — A  man,  twenty-two  years  of  age,  complains  of  gradually 
increasing  pain  in  the  throat  and  a  burning  sensjition  on  the  tongue 
for  the  past  three  weeks.     In  other  respects,  he  says,  he  is  healthy. 

Both  tonsils,  especially  the  left  one,  are  slightly  swollen  and  red- 
dened, while  the  central  portion  of  each  tonsil  is  covered  by  a  delicate, 
milky,  translucent  exudate,  dotted  in  places  by  a  greenish-yellow  dis- 
coloration. A  similar  exudate  covers  the  posterior  fauces  on  the  right 
side  and  the  tip  of  the  tongue. 

The  softness  of  the  exudate  and  the  discolored  areas,  suggesting  a 
tendency  to  ulcers,  the  multiple  character  of  the  lesions,  and  freedom 
of  the  posterior  wall  help  to  make  the  picture  of 

Mucous  Patches 

or  syphilitic  papules.  From  diphtheria  the  condition  is  distinguished 
by  the  more  gradual  onset,  the  absence  of  fever,  etc.,  and  the  chronic 
course.  Thrush  is  characterized  by  the  presence  of  mycelium  and 
more  discrete  character  of  the  patches  of  exudate  (see  Plate). 

Pig.  3. — A  married  (!)  lady,  twenty-eight  years  of  age,  complains 
of  pain  in  the  left  side  of  the  throat,  especially  during  the  act  of 
swallowing.  The  pain  came  on  two  weeks  ago  and  has  been  steadily 
getting  woi-se.  The  left  ear  is  also  painful,  and  pain  is  felt  at  the 
angle  of  the  jaw  during  mastication. 

The  region  of  the  angle  of  the  left  jaw  is  slightly  swollen  and  very 
painful ;  enlarged  glands  can  be  felt  on  deep  palpation.  The  left 
tonsil  is  very  prominent  and  intensely  red ;  the  inner  border  is  some- 


Fig.l. 


Tah.W. 


^^^#f 


sgW^-,. 


"mi 


Fig.  2. 


Fiff.3. 


LUh.  Anst  F.  Reichhjolit .  Miiivdim 


7ah.II. 


/>^il5*l 


\ 


r 


hiu.it. 


Lith.  Aiwt  F.  Reichhold.  Miinrhen . 


what  nodular,  and  the  upper  portion  of  the  inner  border  is  interi'upted 
by  an  ulcer  half  the  size  of  a  bean,  with  sharp  edges  and  floor  covered 
with  yellow  exudate.  The  ulcer  encroaches  on  the  surface  of  the  tonsil. 
A  similar  ulcer  is  found  on  the  anterior  surface  further  down,  partially 
hidden  by  the  base  of  the  tongue,  and  a  tiiird  still  smaller  ulcer,  the 
center  of  which  has  not  as  yet  become  depressed,  occupies  the  middle 
of  the  tonsil. 

The   unilateral   distribution,    rapid   couree,   presence   of  pain,   and 
chai-acteristic  appearance  establish  the  diagnosis  of 

Tertiary  Syphilitic  Ulcer  of  the  Tonsil. 


PLATE  11. 

Fig.  1. — The  color  of  the  pharynx  is  normal,  and  the  two  tonsils 
present  a  symmetric  enlargement.  The  surface  is  pale,  travelled  by 
one  or  two  blood-vessels,  and  distinctly  shows  the  lacunae,  with  here 
and  there  a  few  yellowish-white  nodules.     It  is  a  simple 

Tonsillar  Hypertrophy. 

The  appearance  alone  indicates  the  origin  of  the  condition,  which 
results  from  various  kinds  of  inflammations  tending  to  increase  the  size 
of  the  lacunse  and  to  bring  on  fatty  degeneration  or  calcification  of  indi- 
vidual follicles  represented  by  the  yellowish-white  nodules. 

Fig.  2. — The  throat  of  a  man,  fifty  yeare  of  age,  is  greatly  thickened 
in  front  and  on  the  left  side.  It  is  surrounded  by  a  firm,  lobulated 
tumor,  adherent  at  the  region  of  tiie  angle  of  the  jaw,  and  merging  in 
front  and  below  into  a  dense,  infiltrated  tissue  adherent  to  the  skin. 
The  tumor  is  surrounded  by  one  or  two  hard  glands,  from  the  size  of  a 
pea  to  that  of  a  bean,  which  are  not  painful  and  retain  some  degree  of 
mobility.  The  tumor  attained  its  present  size  in  the  course  of  three 
months.  ThLs  indicates  that  in  spite  of  the  rapid  growth  the  surface 
has  not  degenerated.  The  unilateral  character,  rapid  growth,  and  con- 
sistency of  the  tumor  point  toward  malignancy,  and  this  is  confinmed 
by  the  glandular  enlargement  in  the  neck.     It  is  a 

Primary  Sarcoma  of  the  Tonsil, 

although  the  anatomic  diagnosis  cannot  be  assured  without  excising  a 
fragment  for  examination. 


PLATE  12. 

Fig.  1. — A  man,  forty-eight  yeai-s  of  age,  has  had  several  pharyn- 
geal polyps  removed  at  short  intervals  during  the  past  six  months.  He 
presents  himself  on  account  of  jmin  radiating  to  the  ear  and  difficulty 
m  opening  the  mouth,  conditions  that  have  developed  recently.  The 
complexion  is  bronzed  and  somewhat  anemic ;  the  same  applies  to  those 
mucous  membranes  that  are  visible.  The  mouth  can  only  partially  be 
opened. 

The  site  of  the  right  tonsil  is  occupied  by  a  dark-red  tumor  about 
the  size  of  a  walnut,  with  irregular,  maramillated,  almost  nodular  sur- 
face, which  gradually  fades  away  into  the  tongue  below  and  the  velum 
above,  without  any  distinct  demarcation.  The  posterior  faucial  arch 
as  far  as  it  is  visible  is  thickened  and  somewhat  reddened.  The  surface 
of  the  tumor  presents  several  greenish-yellow,  shallow  ulcei-s.  The 
tumor  is  traversed  and  surrounded  by  a  number  of  dilated  veins. 

The  appearance,  in  combination  with  the  unilateral  character,  suf- 
fices for  the  diagnosis  of  malignant  growth.     It  is  a 

Carcinoma  of  the  Tonsil. 

On  inspecting  and  palpating  the  outer  side  of  the  neck  it  is  found 
that  the  neoplasm  is  extending  toward  the  angle  of  the  jaw,  where  there 
is  a  hard,  diffuse  swelling  adherent  to  the  skin  ;  in  its  immediate  neigh- 
borhood several  small  haixi- glands  can  be  felt.  Microscopic  examina- 
tion later  brought  anatomic  confirmation  of  the  diagnosis. 

Fig.  2. — In  examining  the  pharynx  of  a  woman,  twenty-five  years  of 
age,  who  had  contracted  an  acute  disease,  the  anterior  surface  of  the 
posterior  arch  on  the  right  side  was  found  occupied  by  a  flat,  round 
eminence,  bluish-white  in  color,  and  about  half  the  size  of  a  lentil. 

Palpation  with  a  probe  shows  that  the  tumor  everywhere  is  slightly 
raised  above  the  surrounding  level,  except  the  lower  portion,  which 
has  slightly  overhanging  edges.  The  patient  knows  nothing  about  the 
condition.     The  provisional  diagnosis  will  have  to  be  a 

Neoplasm — Probably  Benign. 

On  microscopic  examination  of  the  excised  tumor  an  indefinite  type 
of  connective  tissue  was  found,  so  that  the  subsequent  course  will  have 
to  establish  the  diagnosis  definitely. 


lab.  12. 


iig.l. 


Eiff.2. 


Tnh.J3. 


Iig.l. 


hig.^. 


iUJi.  Anst.F.  Reidihnld,  Miutrhen. 


PLATE  13. 

Fig.  1. — At  the  beginning  of  the  third  week  of  typhoid  fever,  patches 
appeared  in  the  mouth  of  a  man,  twenty-three  years  of  age. 

The  intermaxillary  fold  of  the  right  side,  the  posterior  faucial  arch 
of  the  same  side,  and  the  soft  palate  are  covered  with  small  whitish 
exudates  about  tlie  size  of  a  lentil.  The  exudates  are  surrounded  by  a 
deeply  injected  areola  and  slightly  raised  above  the  surrounding  level. 
The  center  is  somewhat  depressed  and  of  a  yellowish  color.  These 
are  typical 

Typhoid   Ulcers. 

Fig.  2. — A  gentleman,  forty-seven  years  of  age,  infected  with  lues 
in  earlier  life,  and  recently  treated  for  syphilitic  manifestations  in  the 
larynx,  was  attacked  by  severe  pain  in  the  throat  two  days  ago,  and  yes- 
terday had  an  attack  of  fever  with  chill.  This  morning  the  tempera- 
ture was  38.3°  C.  (100.9°  F.). 

The  pharynx  is  greatly  reddened,  especially  in  certain  ai"eas,  and 
occupied  by  two  or  three  groups  of  lesions.  On  the  posterior  wall  are 
two  small  yellow  vesicles.  The  velum  on  the  right  side  presents 
sevei"al  yellowish,  discolored,  shallow  ulcers ;  on  the  left  side  there  is 
also  a  delicate,  whitish  exudate  of  some  extent. 

Disregarding  the  history  of  syphilis,  which  is  misleading,  the  appear- 
ance of  the  eruption,  its  grouped  arrangement,  combined  with  the 
paroxysmal  character  of  the  fever,  clearly  indicates  that  the  disease  is 

Pharyngeal   Herpes. 

The  picture  presents  the  three  stages  of  herpes  formation, — vesicles, 
ulcei-s,  and  membranous  exudate, — as  it  happens  that  there  are  three 
groups  of  lesions  which  have  appeared  at  the  intervals  corresponding 
to  these  stages  in  their  development. 


PLATE  14. 

Fig.  1. — A  man,  sixty-four  yeai-s  of  age,  who  is  a  frequent  sufferer 
from  indigestion  and  gastric  trouble,  complains  of  severe  pains  in  the 
throat  for  the  past  two  days.  The  soft  palate  and  uvula  are  intensely 
reddened  and  of  a  velvety  appearance.  The  surface  is  covered  by  an 
abundant  macular  exudate,  milky-white  in  color,  partly  translucent  and 
partly  opaque,  without  any  regular  armngement.  Aberrant  patches  are 
found  as  far  down  as  the  posterior  faucial  arch  on  the  left  side.  There 
is  no  ulcei~ation  of  the  mucous  membrane. 

The  exudate  is  firmly  adherent ;  when  one  of  the  patches  was 
removed  with  the  forceps  for  pui-poses  of  examination,  it  was  followed 
by  bleeding. 

Under  the  microscope  the  membrane  is  found  to  consist  almost 
exclusively  of  the  mycelium  and  gonidia  of  the  o'idium  albicans.  The 
clinical  picture,  therefore,  is  that  of 

Pharyngeal  Thrush. 

I*"^G.  2. — This  is  the  toothless  mouth  of  an  infant,  which  presents 
two  diseased  patches  on  the  hard  palate,  on  each  side  of  the  middle 
line  between  it  and  the  posterior  extremity  of  the  alveolar  process. 
The  patch  on  the  right  side  presents  the  appearance  of  a  group  of 
slightly  elevated,  milky-white,  irregular  spots,  as  large  as  pin-heads. 
That  on  the  left  side  is  a  yellowish-white  ulcer  about  the  size  of  a  lentil, 
with  coated  floor  and  slightly  i-aised,  dark-red  edges.  The  seat  of  the 
disease  and  its  appearance  point  to 

Bednar's  Aphthous   Stomatitis, 

which  is  here  represented  in  two  stages  that  ordinarily  are  observed 
only  in  succession.  The  group  of  patches  represents  the  early  ap})ear- 
ance,  while  the  lesion  on  the  left  side  of  the  palate — a  solitary  aphtha — 
has  been  produced  by  confluence  of  the  nodules  and  the  addition  of  a 
fibrinous  exudate. 

Fig.  3. — Condition  accidentally  found  in  examining  the  throat  of  a 
man  thirtA'-eight  yeai"S  of  age : 

The  pharynx  is  pale  rather  than  inflamed,  and  the  tonsils,  the 
anterior  faucial  arches,  and  the  lingual  tonsil  are  covered  with  numei'- 
ous  small,  yellowish-white,  somewhat  prominent  deposits.  With  the 
probe  they  can  be  enucleated,  showing  that  they  consist  of  deposits  of 
foreign  matter.  The  nodules  are  spheric  and  of  friable  consistency. 
The  diagnosis  of 

Pharyngomycosis   Leptothricia 

Ls  readily  made. 

The  nodules  consist  chiefly  of  the  mycelium  and  gonidia  of  the 
leptothrix  buccalis  and  of  inspissated  and  calcified  masses  of  secretion. 


Tab.l^. 


Rg.l. 


Eig.2. 


Fig.J. 


LUh.  Anst.  /.'  ReuhJwld.  Mii/ichen 


Tab.  16. 


Iig.l. 


ffi.  Anst.  E  Revchholcl.  Ahinchcu 


Euf.M. 


PLATE  15. 

Fig.  1. — A  man,  about  thirty-five  years  of  age,  presents  himself  for 
treatment.  He  says  he  has  two  holes  in  his  throat.  When  interrogated, 
he  informs  us  that  he  has  very  little  pain  and  that  the  holes  were 
noticed  yesterday  for  the  fii'st  time.  This  is  all  the  history  that  can 
be  obtained. 

The  central  portion  of  the  soft  palate,  up  to  its  junction  with  the 
hard  palate,  is  of  a  dark-red  color ;  the  uvula  is  swollen  and  shortened  5 
at  the  base  of  the  uvula  there  is  a  deep  ulcer  about  the  size  of  a  gi-ain 
of  wheat,  with  pnnched-out  edges,  becoming  more  shallow  toward  the 
tip  of  the  uvula,  where  it  is  also  covered  with  a  yellowish  exudate.  A 
similar  deep  ulcer,  but  without  any  shallow  portion,  is  found  above 
and  farther  to  the  left  side. 

The  swelling,  the  intense  redness,  the  sharply  outlined  edges  of  the 
ulcers,  justify  the  immediate  diagnosis  of 

Syphilitic   Ulcer  of  the  Soft  Palate. 

On  probing,  it  is  found  that  perforation  has  already  taken  place. 

Fig.  2. — A  girl,  who  is  now  fifteen  years  old,  was  treated  by  the 
author  seven  yeai-s  ago  (!)  for  severe  laryngeal  syphilis. 

In  spite  of  urgent  representations  to  the  parents,  the  girl  did  not 
return  for  treatment,  and  now  reappears  for  the  fii'st  time  on  account 
of  a  defect  in  her  speech.  The  latter  is  very  nasal,  and  it  is  very  diffi- 
cult to  understand  what  the  child  says.  Both  anterior  faucial  arches 
are  converted  into  thick  folds  of  tissue.  The  uvula  is  replaced  by 
a  small,  defomied  nodule,  displaced  to  the  right  by  cicatricial  con- 
tractions; the  soft  palate  presents  a  button-hole  perforation  in  the 
median  line,  at  its  junction  with  the  hai-d  palate.  It  appeai-s,  therefore, 
that  destructive  syphilitic  processes  have  occurred  in  the  pharynx 
since  she  was  last  treated,  and  have  left  the  picture  of 

Postsyphilitic   Defects  and  Scars. 


PLATE  16. 

Fig.  1. — A  man,  forty-two  years  of  age,  who  has  been  treated  on 
account  of  an  obstinate  purulent  discharge  from  the  nose,  complains  of 
severe  pains  in  the  throat  for  the  past  three  weeks,  although  there  is 
nothing  to  be  seen  except  a  ditluse  redness. 

Finally,  one  day,  three  yellow  nodules  the  size  of  a  grain  of  barlev 
are  discovered  near  the  base  of  the  uvula,  which  is  greatly  inflamed. 

Nothing  in  the  history  or  in  the  examination  indicates  either  tuber- 
culosis or  syphilis.     The  diagnosis  of 

Miliary  Qummata, 

which  was  made  later  on,  was  based  on  the  rapid  breaking  down  of  the 
nodules,  the  painful,  subacute  coui"se,  and,  finally,  on  the  positive  result 
of  the  therapeutic  test  with  potassium  iodid. 

Fig.  2. — It  is  impossible  to  tell  exactly  how  long  this  woman,  who 
is  thirty-six  years  of  age,  has  been  suHering  from  sore  throat ;  the 
trouble  has  histed  at  least  a  year.  There  are  not  many  subjective 
symptoms,  except  that  lately  the  appetite  has  been  failing;  night- 
sweats  are  becoming  frequent,  and  the  patient  is  losing  flesh  rai)idly. 
In  her  youth  tlie  patient  was  chlorotic.  Both  parents  died  of  pul- 
monary disease. 

In  both  lungs  extensive  consolidation  with  signs  of  ulceration  are 
discovered.     The  sputum  contains  tubercle  bacilli. 

The  uvula,  especially  the  left  half,  is  greatly  thickened  and  deformed, 
the  surface  is  covered  by  numerous  irregular,  dark-red  nodules  with 
soft  edges.  Similar  nodules  are  seen  on  the  anterior  faucial  arch  of  the 
left  side,  which,  as  a  result  of  the  morbid  thickening,  is  in  contact  with 
the  uvula.  Numerous  small,  grayish-yellow  nodules  are  found  higher 
up  on  the  soft  palate.     There  is  no  doubt  that  we  have  to  do  with 

Pharyngeal  Tuberculosis  Resembling  Lupus, 

a  diagnosis  that  is  borne  out  not  only  by  the  histoiy  and  the  condition 
of  the  lungs,  but  also  by  the  appearance  of  the  tumor,  which  is  infil- 
trated, of  slow  growth,  and  not  ulcerated  on  the  surface. 

Fi(i.  .3.' — The  upper  lip  presents  irregular,  lobulaled  enlargement, 
and  the  edge  is  covered  with  shallow  ulcei-s  resembling  rhagades,  the 
floors  of  which  are  covered  with  a  greenish-yellow  exudate.  The  soft 
palate  is  of  a  dark-red  color.  On  the  posterior  wall  of  the  pharynx, 
immediately  behind  the  posteiior  faucial  arch  on  the  left  side,  there  is 
a  small,  yellow,  oval  tumor  the  size  of  a  pea,  the  surface  of  which 
presents  a  dull  luster.  The  uvula  is  covered  by  a  whole  group  of 
similar  growths,  somewhat  smaller  in  size,  and  surrounded  by  a  bright- 
red  areola.     The  phenomena  are  caused  by 

Lepra  in  its  Early  Stage- 
so-called  lepra  tuberosa.     The  difference  between  this  picture  and  the 
nodular  tuberculous  infiltration  represented  in  the  foregoing  picture  is 
striking.     The  chief  points  of  distinction  are  the  circumscribed  char- 
acter of  the  nodules,  their  greater  size,  and  waxy  yellowish  appearance. 

i  From  Mikulicz  and  Michelson's  AtUu. 


Tab. 16. 


Fig  J. 


Fig.  2. 


Fig.i. 


Lith. .inst  E Rek/ihoUl  .UttiirJien . 


Tab.  17. 


Fig.l. 


*£^       £> 


Fig.S. 

LUh.  Anst  F-  ReicfUiold,  Mtiiichen . 


Fiff.J. 


PLATE  17. 

Fig.  1. — The  case-history  and  description  of  this  figui-e  will  be  found 
opposite  Plate  1,  Fig.  1. 

Fig.  2. — A  young  woman,  twenty-eight  yeai-s  of  age,  has  had  a  sen- 
sation as  of  a  foreign  body  on  the  palate  for  the  past  two  weeks. 

At  the  junction  between  the  pharynx  and  the  soft  palate,  in  the 
median  line,  is  a  dark-red  elevation  about  1  cm.  in  diameter,  with  a  cen- 
tral flat  depression  of  a  bluish-white  color.  Somewhat  dilated  vessels  pass 
from  the  periphery  toward  the  center  of  the  growth.  The  appearance 
corresponds  to  that  of  a 

Broad  Syphilitic  Papule. 

The  diagnosis  is  confimied  by  finding  a  macular  eruption  on  the 
entire  body  and  glandular  enlargements  in  various  regions. 

Fig.  3. — This  patient  is  a  woman,  thirty-nine  yeare  of  age,  who  is 
otherwise  quite  healthy.  For  the  past  three  yeai-s  she  has  been  trou- 
bled with  a  gradually  progressing  dryness  and  obstruction  of  the  nose, 
followed  later  by  redness  and  swelling  of  the  tip  of  the  nose.  For  the 
past  six  months  she  has  also  noticed  a  progi-essive  swelling  of  the  palate. 

The  woman  is  strongly  built  and  well  nourished.  The  internal 
organs  are  normal.  The  external  nose  is  very  red,  and  at  the  junction 
with  the  upper  lip  there  is  a  small,  red  nodule.  The  septum  is  thick- 
ened, light-red  in  color,  and  granular,  as  are  also  the  inner  surfaces  of 
both  alse  nasi,  which  are  more  rigid  than  normal. 

About  the  middle  of  the  hard  palate,  in  the  region  of  the  incisive 
canal,  there  is  a  spheric  area  of  infiltration  about  the  size  of  a  dime, 
somewhat  raised  above  the  surface,  whitish-red  in  color,  and  slightly 
granular.     The  center  is  marked  by  a  flat  depression. 

The  probe  passes  down  to  the  naked  bone  without  detecting  any 
roughness  or  entering  a  perfoiution.  From  the  history  and  appearance 
the  nasal  affection  is  unquestionably  tuberculous,  and  the  condition  in 
the  palate  may  equally  be  pronounced 

Tuberculosis  of  the  Hard  Palate. 

The  integrity  of  the  bone  is  a  proof  that  the  palatal  condition  is  not 
directly  continuous  with  that  in  the  nose.  The  infection  probably  trav- 
eled from  the  floor  of  the  nose  by  way  of  the  lymphatic  clefts  of  the 
incisive  foramina. 


PLATE  18. 

Fig.  1. — A  middle-aged  gentleman  suffere  a  good  deal  of  annoyance 
fix)m  a  feeling  as  of  a  foreign  body  in  the  throat  and  from  attacks  of 
convulsive  coiigii.  It  is  evident  from  liis  questions  that  he  fears  cancer 
or  tuberculosis. 

The  throat  is  normal  in  color ;  the  posterior  wall  is  dotted  over  with 
spheric,  oval,  or  linear,  slightly  reddened  prominences.  Behind  the 
palatopharyngeal  arches  on  both  sides  a  colmunar  arrangement  of  sim- 
ilar tissue  is  also  found. 

The  abnormal  structures  present  the  same  color  and  glaze  as  the 
surrounding  mucous  membrane.     These  submucous  growths  are  due  to 

Pharyngitis  Granulosa  et  Lateralis  Hypertrophica, 

as  the  affection  is  somewhat  inaccurately  called,  since  there  is  no  inflam- 
matory element.  The  latei-al  growths  are  due  to  hypertrophy  of  the 
salpingopharyngeal  folds. 

Fig.  2. — This  woman,  who  is  sixty-four  years  of  age,  has  noticed 
for  the  past  six  months  that  there  was  something  wrong  in  her  throat ; 
but  she  paid  no  further  attention  to  it,  until  lately,  when  severe  pains, 
coming  on  especially  during  the  act  of  swallowing  and  radiating 
toward  the  left  ear,  made  their  appearance. 

The  woman  is  very  anemic  and  has  evidently  lost  flesh. 

Behind  the  soft  palate,  which  is  drawn  down  with  a  tenaculum,  on 
the  posterior  pharyngeal  wall,  there  is  a  flat  swelling  occupying  the 
entire  width  of  the  wall  and  adherent  on  the  left  side  to  the  posterior 
faucial  arch.  The  lower  border  of  the  swelling  is  sharply  defined.  The 
surface  of  the  swelling  is  rough  or  mammilated,  and  dotted  over  with 
red  and  yellow  ;  there  are  also  two  distinct  superficial  ulcei-s  of  a  gray- 
ish-yellow color. 

Underneath  the  angle  of  the  jaw  on  both  sides,  and  along  the 
muscles  of  the  neck  on  the  left  side,  are  several  hard  glands  about  the 
size  of  a  pea,  not  sensitive  to  the  touch.  The  findings  all  point  to  a 
malignant  neoplasm — a 

Carcinoma  of  the  Pharynx, 

which  has  evidently  originated  in  the  nasopharynx. 


TabJS. 


Ftg.l 


W^  ^^'^- 


1 


Tab.W. 


Fig.1. 


Fiff.J. 


PLATE  19. 

Fig.  1. — A  woman,  twenty-eight  yeai-s  of  age,  has  suffered  violent 
pain  on  swallowing  and  headache  for  several  weeks  past.  Her  geneiul 
condition  is  wretched,  and  she  has  lost  a  g(xxi  deal  of  hair. 

Several  purulent  crusts  are  seen  adhering  to  the  posterior  wall  of 
the  pharynx,  and  above  the  crust^j  there  appears  to  be  an  ulcer. 

After  the  soft  palate  has  been  drawn  aside  with  a  palate  retractor 
the  left  side  of  the  nasal  portion  of  the  posterior  wall  of  the  pharynx 
is  seen  to  be  occupied  by  a  flat  swelling,  marked  by  two  punched-out 
ulcers,  and  presenting  in  the  left-hand  portion  a  bluish-red  color.  The 
upper  ulcer  is  half  hidden  from  view.  The  floors  of  both  ulcers  are 
covered  with  a  yellowish,  discolored  exudate,  and  from  the  lower  there 
is  also  some  discharge  of  yellowish-green,  tenacious  pus. 

The  history  is  very  indefinite,  but  even  without  it  the  condition  can 
be  pronounced  without  hesitation  an 

Ulcerating  Gumma. 

Fig.  2. — On  account  of  frightful  pain  in  the  throat  lasting  three 
weeks,  a  woman,  thirty  yeai-s  of  age,  has  finally  consulted  the  physician, 
too  late,  however,  as  may  be  seen  at  the  fii-st  glance. 

The  site  of  the  right  tonsil  is  occupied  by  an  extensive  ulcer,  cov- 
ered with  a  yellowish,  lardaceous  exudate  and  with  slightly  indented 
margins,  the  median  portion  extending  deep  into  the  tissues.  The  pos- 
terior faucial  arch  on  the  right  side  is  greatly  thickened  and  slightly 
granular.  A  similar  ulcerated  surface  extends  upwaixi  into  the  hani 
palate.  The  remainder  of  the  soft  palate  has  become  adherent  to  the 
posterior  wall  of  the  pharynx,  so  that  this  ulcer  extends  from  the  hard 
palate  to  the  pharynx  and  below  as  far  as  the  level  of  the  base  of  the 
tongue.  The  central  portion  is  distinctly  deeper  than  the  rest  of  the  ulcer, 
and  has  a  sharply  punched-out  appearance.  On  the  left  side  there  is  a 
prominent  mass  of  tissue  representing  the  uvula,  which  is  drawn  down- 
wai-d  and  to  the  left,  greatly  swollen,  ajid  of  a  granular,  red  appeai-ance, 
so  that  it  cannot  be  recognized  by  either  its  position  or  its  outline. 

It  is  obvious  that  an  acute  destructive  process  like  the  present  oblit- 
erating of  anatomic  relations,  and  in  which  ulceration  goes  hand  in 
hand  with  cicatrization,  can  be  due  only  to 

Tertiary  Syphilis. 

Fig.  3. — During  a  laryngeal  examination  of  a  woman  between  thirty 
and  forty  years  of  age  the  appearance  of  the  phaiynx  attracted  the 
surgeon's  attention. 

In  the  anterior  faucial  arch  on  the  right  side  there  is  to  be  seen 
an  oval  defect  with  smooth  edges,  surrounded  by  pale  but  otherwise 
normal  mucous  membrane.  A  similar  defect  is  seen  higher  up  on  the 
soft  palate,  above  the  uvula,  but  the  mucous  membi-ane  surrounding  it 
is  drawn  into  pale,  tense  folds.  Similar  radiating  folds  are  found  in  the 
central  portion  of  the  posterior  wall  and  on  the  left  faucial  arch, 
binding  the  latter  firmly  to  the  posterior  wall  of  the  phaiynx,  and 
causing  a  retraction  of  the  entire  velum  to  the  left.    The  uvula  is 


repivsentwl  by  a  mere  nuliineiit  in  the  shape  of  a  slight,  wavy  promi- 
nence.    Tlie  pallor  of  the  entire  throat  is  noliceiible. 

The  defects  are  i)erfomtions,  the   folds  are  hard  cicatricial  bands, 
such  as  are  found  as  the 

Cicatrized  Syphilitic  Ulcers. 

The  clean  appearance  of  the  defects,  the  hardness  and  intense  white- 
ness of  the  scars,  and  the  general  pallor  are  chamcteristic  features. 


PLATE  20. 

Fig.  1.— This  presents  a  view  of  the  left  choana,  seen  from  in  front. 
The  wide  view  wa.s  made  possible  in  this  cjuse  by  marked  destruction 
of  the  middle  turbinate  (c).  The  posterior  wall  of  the  pharynx  (d) 
is  visible  and  appears  formed  by  the  choana,  which  is  bounded  inter- 
nally by  the  septum,  below  by  the  floor  of  the  nose  (o),  to  the  outer  side 
by  the  lower  turbinate  (6)  and  by  the  Eustachian  fold  (e).  Above  the 
lower  turbinate  a  small  portion  of  the  tubal  opening  (0  is  visible.  It 
is  the  picture  of  the 

Eustachian  Tube  in  the  Quiescent  State, 
while  No.  2  represents  the 

Eustachian  Tube  During  Deglutition. 

In  the  latter  position  it  projects  some  distance  into  the  lumen  of  the 
choana,  and  has  a  club-shaped  outline.  The  mouth  of  the  tube  is  wide 
open  (<) ;  the  interval  between  it  and  the  lower  turbinate  is  occupied 
by  a  triangular  fold  of  mucous  membmne  (</).  The  posterior  surface 
of  the  velum  thus  cuts  off  communication  with  the  nasopharyngeal 
space  from  below.  This  illusti-ation  readily  explains  why  fluid  in  the 
nose  is  liable  to  be  forced  into  the  tube  during  the  act  of  swallowing. 
Fig.  2. — This  represents  the  nose  of  a  girl  thirteen  yeare  of  age. 
The  chambers  are  so  wide  that  on  the  left  side  the  entire  choana, 
and  on  the  right  at  least  half  of  the  posterior  naris,  can  be  seen. 
Framed  by  the  choana  and  occupying  the  posterior  wall  of  the  phaiynx 
are  several  pale-red  structures  with  a  slightly  nodular  surface  somewhat 
resembling  a  mulberry.  On  the  left  side  the  growth  gradually  merges 
into  a  smooth,  slightly  elevated  tumor  on  the  outer  and  lower  side. 
This  unusual  condition,  permitting  a  view  of  the  phaiynx  directly 
through  the  nose,  enables  us  to  see  the 

Hypertrophied  Pharyngeal  Tonsil, 

which  in  addition  occupies  a  very  low  position. 

Fig.  3. — The  vault  of  the  nasopharynx  in  a  woman  twenty-six  yeare 
of  age  is  filled  with  a  mass  of  pale-red  nodular  bodies  hanging  down 
almost  to  the  upper  edge  of  the  choana.  The  surface  of  the  nodules  is, 
on  the  whole,  smooth  and  shiny.  The  seat  and  appearance  of  th^ 
growths  identify  them  as 


Tab.20. 


Fiff-]. 


Ficf.S. 


Fig.3. 


LUh.  Anst  E  Reicfdwld.  Miinchen. 


7'ab.:'/. 


Fig.  ^. 


LUIi.Anst  /■:  ReicMtoUl  Mwirlien 


Adenoid  Vegetations, 

the  well-known  proliferations  of  lynij)hadenoid  tissue  or  so-called 
pharyngeal  tonsil.  Although  the  hypertrophy  is  only  moderate  in 
degree,  there  is  a  good  deal  of  interference  with  nasal  respimtion.  The 
patient  complains  of  this  obstruction,  as  well  as  of  marked  impairment 
in  phonation,  so  that  the  voice  is  muffled  like  the  tone  of  a  violin  played 
with  a  sordine  (damper). 

PLATE  21. 

Fig.  1. — A  young  man,  twenty-two  yeai-s  of  age,  h;is  come  to 
consult  the  doctor  for  violent  headache  and  pain  in  the  throat  radi- 
ating to  both  ears,  a  general  feeling  of  depression,  pain  in  the  limbs, 
constipation,  alternating  chills,  and  a  feeling  of  heat.  These  symp- 
toms have  existed  for  two  days  and  point  to  some  acute  febrile 
disease.  The  tongue  is  thickly  coated,  the  breath  is  fetid,  especially 
when  the  mouth  is  closed ;  nasal  breathing  is  also  somewhat  difficult. 
The  pharynx  is  only  slightly  reddened.  Although  the  severe  general 
symptoms  might  be  explained  by  the  assumption  of  an  influenza  with 
mild  catarrhal  symptoms,  this  would  fail  to  account  for  the  violent 
local  manifestations.  A  posterior  rhinoscopic  examination  is  therefore 
indicated. 

The  upper  portion  of  the  nasopharynx  is  red,  while  numerous 
lobules  of  tissue  closely  crowded  together  overhang  the  choanae,  espe- 
cially on  the  left  side.  They  are  even  more  intensely  reddened  than 
the  surrounding  tissue,  and  present  numerous  small  yellow  masses  of 
exudate  which  appear  to  grow  from  shallow  depressions.  The  lobes 
represent  swollen  lymphadenoid  tissue,  which  is  now  the  seat  of  an 
inflammatory  process  in  every  respect  analogous  to  that  with  which  we 
are  well  acquainted  on  the  palatal  tonsils  (see  Plate  8,  Fig.  1).  We 
have  to  deal  with  a 

Lacunar  Inflammation  of  the  Pharyngeal  Tonsils. 

The  reason  this  affection,  which  is  not  soveiy  rare,  is  not  better  known 
is  that  posterior  rhinoscopy  has  hitherto  usually  been  neglected  in  acute 
affections. 

Fig.  2. — A  woman,  forty-five  yeare  of  age,  was  taken  sick  about  two 
weeks  ago  with  fever  and  mai'ked  general  symptoms,  combined  with 
nasal  obstruction  and  a  feeling  of  diyness  in  the  throat.  On  the  day 
of  examination  she  began  to  perspire  profusely,  and  thus  suddenly  dis- 
charged a  large  mass  of  pus  from  tlie  nose.  After  this  she  felt  very 
much  better  and  began  to  improve,  although  the  weakness  continues. 

Mucopurulent  exudate  is  now  found  on  the  floor  of  the  nose.  The 
middle  portion  of  the  pharynx  is  free.  In  the  nasopharynx  the  roof 
is  greatly  reddened,  and  the  region  of  the  pharyngeal  tonsil  presents  a 
diffuse  swelling.  (To  make  the  picture  somewhat  clearer,  a  purulent 
exudate  which  was  present  has  been  removed.)  It  is  evident  that  we 
have  to  deal  with  the  final  stage  of  a 

Retronasal  Phlegmon. 


PLATE  22. 

Fig.  1. — This  patient,  a  gentlemau  forty-two  years  of  age,  df.scribes 
his  malady  as  a  "chronic  pharyngeal  catarrh."  He  cliokes  and  liawks 
a  good  deal,  especially  in  the  morning,  and  expectorates  tough,  yellow- 
ish-green mucus  with  a  great  deal  of  difficulty.  The  throat  feels  dry, 
and  he  often  has  a  sensation  as  if  there  was  something  in  it. 

The  mucous  membrane  of  the  posterior  wall  of  the  pharynx  is  dry, 
and  covered  with  a  thin,  tenacious  layer  of  mucopurulent  exudate. 

Posterior  rhinoscopy  :  The  left  side  of  the  vault  presents  several  flat 
swellings  of  the  same  color  as  the  adjacent  mucous  membrane.  Between 
the  larger  one  on  the  right  side  and  a  group  of  smaller  ones  there  is  a  deep 
cleft,  fr/)m  the  lower  extremity  of  which  a  purulent,  inspissated  secre- 
tion is  discharged  over  the  septum  to  the  po.sterior  surface  of  the  soft 
palate. 

Tlie  swollen  tissue  is  to  be  interpreted  as  the  remains  of  adenoid 
tissue,  which  sometimes  persist  to  middle  age,  and  the  cleft  between 
them  is  designated  as  the 

Recessus  Pharyngeus   Lateralis. 

A  similar  cleft  is  often  present  in  the  middle  of  the  i)harynx,  corre- 
sponding to  the  point  where  the  mucous  membrane  is  more  intimately 
attached  to  the  bone.  The  secretory  process  which  is  kept  up  by  an 
inflammation  within  the  cleft  is  known  as 

Localized  Retronasal  Catarrh. 

Fig.  2. — A  man,  twenty-eight  years  of  age,  ever  since  he  was  a  boy 
has  ejected  both  through  the  nose  and  mouth  tough,  greenish-yellow 
crusts  filling  the  entire  nose.  He  has  been  told  that  the  crusts  are  olTen- 
sive.     He  himself  has  no  sensation  of  smell. 

The  nose  is  entirely  filled  with  crusts,  which  emit  a  horrible  fetor. 
Behind  the  crusts  is  some  more  fluid  secretion.  The  mucous  membranes 
are  pale,  and  the  turbinates  are  contracted  so  that  the  width  of  the 
nasal  chambers  is  conspicuous. 

The  structures  of  the  nasopharyngeal  space  are  smaller  than  normal 
in  every  measurement ;  they  are  "  emaciated."  The  general  appearance 
of  the  mucous  membrane  is  pale,  except  for  a  thickened  portion  above 
the  right  choana,  which  is  slightly  reddened.  Below  this  tlure  projects 
a  grayish-green,  dry  mass,  evidently  consisting  of  inspissated  secretion, 
which  extends  from  that  point  over  the  septum  and  the  choana  as  far  as 
the  posterior  surface  of  the  soft  palate,  concealing  portions  of  the 
turbinates. 

The  condition,  which  is  commonly  spoken  of  as 

Fetid  Atrophic  Rhinitis  or  Ozena, 

merely  tells  us  that  a  purulent  process  is  at  work,  probably  in  the  region 
of  the  swollen  mass  of  tissue  described.  The  products  of  this  purulent 
process  meet  with  obstacles  in  their  passage  through  the  nose,  and  thus 
gain  time  to  dry  out.     As  a  matter  of  fact,  we  have  to  deal  with  an 

Empyema  of  the  Right  Sphenoid  Sinus, 

a  suppuration  in  the  right  sphenoid  sinus,  from  the  lower  wall  of  which 
the  secretioa  is  discharged. 


Tab.22. 


Iig.l. 


Fig.  2. 


Ltth.  An.t/  F.  ReUhiuild .  Mundien. 


Tab. 2.3. 


Fig.]. 


Fig.Ji. 


l.ith.  Anst  /■:  RpichhoUL  Manchen. 


PLATE  23. 

Fig.  1. — A  woman,  fifty-six  years  of  age,  complains  of  obstmction 
in  the  nose  and  some  discharge.  She  says  her  troubles  date  back  only 
a  week  or  two.  An  anterior  view  of  the  nose  presents  nothing  unusual, 
but  the  posterior  extremities  of  the  turbinates  appear  to  be  somewhat 
thickened. 

The  entire  vault  is  filled  by  a  grayish-red,  slightly  nodular  mass, 
which  merges  into  the  tubal  folds  without  any  distinct  delimitation. 
The  vomer  and  the  posterior  choana  present  a  similar  appearance.  On 
palpation,  the  tumor  feels  soft  and  somewhat  friable,  and  at  once  begins 
to  bleed. 

The  history  is  undoubtedly  incorrect.  The  patient  is  of  a  torpid 
disposition,  and  although  symptoms  of  the  disease  must  have  been 
noticeable  for  some  time,  paid  no  attention  to  them  until  the  entiunce 
of  air  was  completely  cut  ofT.  The  tumor,  which  has  infiltrated  the 
surrounding  tissue  and  set  up  a  degenerative  process,  can  be  nothing 
but  a  malignant  neopla.sm  which  has  existed  for  at  least  six  months. 
A  fragment  removed  for  purposes  of  examination  reveals  under  the 
microscope  its  nature.     It  is  a 

Sarcoma  of  the  Nasopharynx. 

Fig.  2. — A  woman,  thirty-four  years  of  age,  has  been  troubled  with 
a  gradually  increasing  obstruction  of  the  nose  for  the  past  two  to  thi-ee 
weeks.     Anterior  rhinoscopy  is  negative. 

Posteriorly,  on  the  other  hand,  the  fornix  is  found  to  be  covered  by 
a  bluish-red  tumor,  slightly  elevated  above  the  surrounding  level,  and 
with  a  somewhat  uneven  surface.  The  tumor  partially  overhangs  the 
tubal  folds. 

The  woman  has  had  several  miscarriages.  Two  children  died  during 
the  first  months ;  the  last  one  is  the  only  one  that  lived,  and  is  now 
well.  Lately  she  has  had  marked  defluvium  capillorum,  and  she  often 
suffers  from  headache.  These  things  all  point  to  lues.  The  general 
appearance  of  the  tissues,  and  the  painless,  febrile,  subacute  course  of 
the  inflammation  are  in  harmony  with  this  diagnosis.  We  have  to  do 
with  a 

Retronasal  Qumma. 


PLATE  24. 

Fig.  1. — Pain  in  the  throat  and  ears  occurring  simultaneously  in  a 
girl  sixteen  years  of  age  suggests  the  propriety  of  making  an  otoscopic 
examination.  Both  drumheads  are  slightly  reddened  and  bulging, 
especially  the  left.     The  hearing  is  reduced  to  whis{)ering  at  10  cm. 

Rhinoscopy ;  The  vault  presents  slight,  wavy  ridges,  arranged  in 
two  parallel  rows,  and  extending  laterally  as  far  as  Eosenmiiller's 
fossa. 

The  tulwl  folds,  of  which  the  internal  surfaces  are  chiefly  seen  (by 
rotating  the  mirror  outward),  are  intensely  red  and  somewhat  swollen. 

Yellow  pus  exudes  from  the  opening  of  the  left  tube,  and  on  the 
right  side  a  drop  of  gravish  mucus  is  seen  issuing  from  the  tube.  We 
evidently  have  to  do  witli 

Acute  Salpingitis. 

The  discovery  of  an  acute  otitis  media  tells  us  that  the  discharge 
comes  not  only  from  the  miicous  membrane  of  the  tube,  but  also  from 
the  middle  ear.  The  ridges  on  the  vault  of  the  pharynx  represent 
ill-developed  adenoid  vegetations. 

Fig.  2. — A  man,  thirty-eight  years  of  age,  complains  of  pain  in  and 
over  the  right  eye  for  the  past  week.  The  examination  of  the  eyes  is 
negative.  The  patient  states  that  he  has  recently  had  a  free  discharge 
of  pus  from  the  right  nostril.  Owing  to  a  marked  deviation  of  the 
septum,  it  is  almost  impossible  to  obtain  a  view  from  in  front. 

The  vault  of  the  pharynx  is  covered  with  pus,  and  the  adenoid 
tissue  is  considerably  swollen.  The  upper  nasal  meatus  is  entirely 
occluded  by  intense  swelling  of  the  greatly  reddened  middle  turbinate, 
the  surface  of  which  is  very  irregular.  The  inferior  turbinate  presents 
similar,  though  less  marked,  changes.  From  the  middle  meatus  pus 
flows  over  the  vomer  and  bathes  the  posterior  surface  of  the  soft  palate. 
It  is  the  picture  of 

Acute  Nasal  Suppuration, 

which  cannot  be  more  accurately  localized  as  we  cannot  exclude  a  pos- 
sible suppuration  from  an  accessory  cavity  in  addition  to  the  evident 
disease  of  the  nasal  pas.sages. 

(The  inflammation  disappeared  in  three  weeks  under  non-irritating 
treatment ) 


Tab. 24. 


Litfi.  Arist  /;  RjeirhhoUl.  Miuichen . 


Tub.  2.7 


Ficf.2. 


ficf.l. 


fiff.J. 


LUh.  Anst  /.'  Reiduiolil.  Miiiichen. 


PLATE  25. 

Fig.  1. — A  man,  thirty-four  years  of  age,  complains  of  nasal  obstruc- 
tion and  frequent  small  hemorrhages  from  the  nose,  as  well  as  violent 
headache.  The  symptoms  have  existed  about  two  weeks.  On  anterior 
inspection,  the  left  lower  turbinate  particularly  is  found  to  be  greatly 
enlarged.  The  entire  left  half  of  the  postnasal  space  is  intensely  red. 
Above  the  left  choaiia  there  is  a  sharp-cut,  horizontal  defect,  with  some- 
what swollen  and  greatly  reddened  margins,  the  floor  of  which  is  cov- 
ered with  a  greenish-yellow  exudate.  The  left  choaiia  is  occluded  by 
the  middle  turbinate,  which  presents  irregular  swelling  and  intense 
redness,  besides  a  similar  deep,  punched-out,  and  ragged  defect.  From 
the  latter,  pus  is  oozing  down  over  the  edge  and  left  wall  of  the  septum. 
The  inferior  turbinate  and  the  left  tubal  fold  are  red  and  swollen.  The 
appearance  of  the  sharp-cut  ulcers,  surrounded  by  an  intensely  inflam- 
matory areola,  is  characteristic  of 

Syphilitic  Ulcers  of  the  Nasopharyngeal  Vault. 

They  are,  of  course,  tertiary  lesions.  Six  months  later  the  following 
picture  was  seen  : 

Fig.  2. — Both  choanae,  especially  the  left,  are  narrowed,  and  their 
outlines  are  greatly  altered.  This  alteration  is  due  to  a  broadening  of 
the  septum,  amounting  to  four  or  five  times  its  normal  width,  and  is 
especially  marked  in  the  upper  portion.  In  addition,  the  inferior  and 
middle  turbinates  on  the  left  side  are  widened  and  deformed,  so  that 
the  boundary-line  between  the  middle  turbinate  and  the  outer  edge 
of  the  choana  is  obliterated.     These  alterations  are  all 

Residua  of  Ulcerative  Syphilis 

as  represented  in  Fig.  I.  Hardly  any  external  scars  are  to  be  seen,  but, 
on  the  other  hand,  the  changes  in  the  deeper  tissues  are  all  the  more 
marked.  We  regard  them  as  the  products  of  excessive  inflammatory 
deposits  and  necrotic  destruction  of  tissue. 

Fig.  3.— a  gentleman,  twenty-eight  years  of  age,  was  infected  with 
syphilis  six  years  ago,  and  at  the  time  had  secondary  symi)toms.  Being 
rather  worried  about  it,  although  he  has  had  no  subjective  symptoms,  he 
desires  to  have  his  nose  examined,  especially  as  he  believes  that  during 
the  past  two  months  he  has  occasionally  noticed  a  bad  odor  and  a 
temporary  obstruction  in  the  nose. 

The  mucous  membrane  on  the  upper  half  of  the  septum  is  slightly 
reddened.  Almost  the  entire  septum  is  greatly  narrowed,  the  contours 
are  converted  into  irregularly  serrated  lines,  and  the  mucous  membrane 
shows  a  grayish-green  discoloration.  The  lateral  walls  that  are  visible 
in  perspective  are  somewhat  swollen.  The  picture  is  not  characteristic, 
and  it  requires  an  expericTiced  eye  to  recognize 

Syphilitic  Necrosis  of  the  Vomer, 

which  extends  far  beyond  the  limits  of  the  visible  field. 
The  true  extent  will  be  best  recognized  by  the  accompany- 
ing drawing  (a),  which  represents  a  sequestrum  removed 
from  the  septum.  The  edge  (a)  of  this  sequestrum  cor- 
responds to  the  posterior  surface  of  the  septum,  as  it  is 
seen  in  the  rhinoscopic  image. 

The  syphilitic   nature  of  the   process,  the  terminal 
stage  of  which  is  here  represented,  is  revealed  by  the  absence  of  granu- 
lations, such  as  would  be  found  in  tuberculosis,  and  by  the  comparative 
"cleanliness"  of  the  sequestrum  formation. 


PLATE  26. 

Fig.  1. — A  middle-aged  gentleman  seeks  relief  from  obstruction 
which  almiM  amounts  to  total  abolition  of  na^sal  resj)iration.  In  front 
the  inferior  turbinates  are  seen  to  be  swollen,  although  not  excessively 
so.  The  posterior  extremities  of  the  middle  turbinates  appear  within 
the  frame  of  the  choanae  as  narrow,  club-shaped  structures.  Imme- 
diately underneath,  two  grayish-red,  spheric  bodies  resembling  cauli- 
flower project  above  the  edge  of  the  choana  and  the  septum.  These 
bodies  represent 

Papillary  Hypertrophy  of  the  Posterior  Extremities  of 
the  Inferior  Turbinates. 

Fig.  2. — A  young  man,  twenty-three  years  of  age,  has  experi- 
enced difficulty  in  breathing  for  some  time,  and  for  the  past  three 
months  the  left  side  of  the  nose  has  been  completely  obstructed.  The 
lower  part  of  the  left  choana  is  occluded  by  an  almost  spheric,  smooth, 
grayish-yellow,  slightly  translucent  tumor,  about  the  size  of  a  hazel-nut, 
which  almost  completely  conceals  the  opening  of  the  left  Eustachian 
tube,  as  well  as  the  lower  portion  of  the  middle  turbinate  and  the  sep- 
tum. The  tumor  is  traversed  by  large  blood-vessels.  At  the  fii-st  glance 
it  is  recognized  as  a 

Retronasal  Polyp. 

The  absence  of  adhesions  and  the  integrity  of  the  surface  indicate 
that  the  tumor  is  benign,  and  by  means  of  the  probe  it  is  found  to  be 
attached  by  a  circumscribed  pedicle  from  the  posterior  extremity  of 
the  middle  turbinate. 

Fig.  3. — A  boy,  twelve  years  of  age,  has  been  practically  unable  to 
breathe  through  the  nose  for  almost  a  year.  When  he  tries  to  blow 
his  nose,  he  often  brings  blood.  The  mouth  is  held  wide  open.  On 
anterior  view,  masses  of  mucns  are  found  in  the  nose  and  the  turbinates 
are  seen  to  be  somewhat  thickened.  The  entire  nasopharynx  is  filled 
with  a  brownish-red  tumor  about  the  size  of  a  small  apple,  completely 
occluding  the  right  choana  and  all  but  the  lowest  .segment  of  the  left. 
The  opening  of  the  right  tube  (r  t)  is  completely  concealed,  while  the 
left  (o)  is  just  barely  visible.  The  surface  of  the  tumor  in  places  is 
irregular.  It  grows  by  a  broad  stalk  from  the  roof  of  the  nasoj)haryn- 
geal  space,  and  Is,  in  addition,  attached  to  the  walls  at  two  different 
points  by  adhesions.     No  xilcers  are  visible  on  any  part  of  the  surface. 

The  tumor,  therefore,  is  a  so-called 

Fibroid  of  the  Nasopharyngeal  5pace, 
more  correctly,  juvenile  sarcoma. 


Fig.l. 


Eig.2. 


Fig.3. 


Tah.27. 


Eig.l. 


Fiff.3. 


Anst  /■:  Reirhiwtd,  Miinrh'm . 


Fig.S. 


PLATE  27. 

Fig.  1.— In  the  right  half  of  the  nose  (a,  inferior,  6,  middle  turbi- 
nate) a  spinous  process  with  a  broad  base  projects  horizoutally  from  the 
septum  toward  the  lower  turbinate,  with  which  it  is  in  contact,  so  that 
the  inner  surface  of  the  turbinate  presents  a  shallow  depression.  The 
mucous  membrane  covering  the  cartilage  of  the  septum  is  continuous 
with  that  of  the  spur,  so  that  the  junction  of  the  latter  with  its  base 
cannot  be  made  out.  It  follows,  therefore,  that  the  spur  consists  of  car- 
tilaginous tissue,  and  this  conclusion  is  confirmed  by  the  probe.  It  is 
designated 

Spina  Septi    Cartilaginei. 

The  region  of  the  septum  opposite  the  middle  turbinate  is  greatly 
depressed  on  account  of  the  bending  of  the  cartilage  toward  the  other 
(left)  side. 

The  left  side  of  the  nose  is  encroached  upon  by  a  smooth,  glistening 
wall  of  tissue,  arching  outward  from  the  middle.  The  narrowing  is  so 
extreme  that  only  a  slender  strip  of  the  middle  turbinate  (6)  is  visible. 
It  is  evident  both  from  the  continuity  of  this  wall  of  tissue  with  the 
floor  of  the  nose  and  from  the  fact  that  it  is  entirely  similar  to  the  sep- 
tum in  color  and  consistency,  that  it  is  merely  a  lateral  bulging  of  the 
cartilaginous,  and  possibly  also  of  the  bony,  septum.    It  is,  therefore,  a 

Deviation  of  the  Septum. 

Fig.  2. — A  woman  suffers  from  rather  frequent  attacks  of  inflamma- 
tion, now  of  one  ala  nasi,  now  of  the  other,  the  attack  ending  with  dis- 
charge of  a  small  amount  of  pus  from  the  separation  of  a  small  crust. 

At  present  the  nose  is  free.  On  the  inner  side  of  the  left  ala  nasi 
there  is  a  stellate  scar  of  a  whitish  color,  with  a  central  depression. 
This  represents  the  remains  of  repeated  attacks  of 

Suppurative  Folliculitis  of  the  Meatus  of  the  Nose. 

Fig.  3. — A  youth,  seventeen  years  of  age,  has  had  frequent  hemor- 
rhages from  the  left  side  of  the  nose.  He  is  continually  picking  his 
nose  and  tearing  away  the  crusts  that  form  at  this  point,  a  procedure 
that  is  always  followed  by  renewed  hemorrhage. 

After  carefully  softening  several  flat  crusts  adherent  to  the  left  side 
of  the  vestibule,  a  pure  white,  rather  narrow  strip,  surrounded  by  a  pale- 
red  areola,  is  seen  running  from  before  and  below  backward  and  upward 
on  the  anterior  inferior  portion  of  the  septum.  The  strip  of  tissue  can 
be  removed,  and  there  is  disclosed  underneath  the  ulcerated,  somewhat 
granular,  mucous  membrane,  that  bleeds  readily. 

This  process  is  repeated  with  the  production  of  the  same  appearance 
during  the  next  few  days. 

We  have  to  deal  with 

Traumatic  Erosion  of  the  Wall  of  the  Septum. 

The  exudate  consists  of  epithelium  which  has  undergone  necrotic,  and 
in  part  fibrinous,  alteration. 

Fig.  4.— The  middle  turbinate  (m)  is  greatly  enlarged,  and  almost 
completely  obstructs  the  middle  nasal  meatus.  The  mucous  membrane 
is  slightly  granular  and  of  a  pale-red  color.  As  much  of  the  septum  as 
is  visible  is  traversed  by  a  number  of  ridges,  some  flat,  some  lobalar  in 


PLATE  27  {Continued). 

shape,  and  most  of  them  ruuniug  horizontally.  The  color  of  these  ridges 
is  the  same  as  that  of  the  middle  turbinate.  The  identity  of  this  mucous 
membrane  with  that  of  the  septum  is  unmistakable,  and  the  alfection  is 
designated 

Hypertrophy  of  the  Mucous  Membrane  of  the  Septum. 

Fig.  5.— Between  the  inferior  (m)  and  middle  (»»)  turbinates  on  the 
left  side  there  projects  a  broad,  somewhat  lobular,  red  swelling,  which 
at  first  gives  the  impression  that  the  middle  turbinate  is  double.  As  a 
matter  of  fact,  the  swelling  has  nothing  to  do  with  the  latter,  as  is 
shown  by  means  of  the  probe.  It  represents  a  hypertrophy  of  the 
inferior  margin  of  the  hiatus  semilunaris ;  it  is  the  so-called 

Lateral   Fold, 

a  hyperplasia  sometimes  produced  by  purulent  or  catarrhal  processes  in 
the  inferior  nasal  meatus  or  adjacent  nasal  cavities. 


PLATE  28. 

Fig.  1. — In  the  right  half  of  the  nose,  above  the  inferior  turbinate, 
which  is  thickened  and  club-shaped,  we  see  a  number  of  spheric,  closely 
aggregated  tumors  obstructing  the  middle  nasal  meatus  as  far  as  the 
septum.  The  tumors  are  of  a  pale,  grayish-yellow  color,  translucent, 
and  contain  numerous  vascular  ramifications.  In  the  left  half  of  the 
nose  a  pear-shaped  tumor  of  similar,  although  somewhat  firmer,  appear- 
ance fills  out  the  choana  as  far  as  the  floor  of  the  nose,  so  that  only  a 
narrow  triangular  strip  of  the  inferior  turbinate  is  visible.  The  appear- 
ance of  the  tumors  alone  assures  the  diagnosis  of 

Nasal  Polypi, 

the  multiple  form  being  represented  in  the  right,  and  the  solitary  form 
in  the  left,  half  of  the  nose. 

It  is  possible  that  the  latter  may  conceal  some  additional  multiple 
polypi.  The  point  of  attachment  of  the  masses  (in  the  middle  nasal 
meatus  and  roof  of  the  nose,  hence  on  the  ethmoid  bone)  will  have  to 
be  determined  by  the  probe.  Careful  attention  must  also  be  given  to 
the  condition  of  the  bone  (caries)  and  the  presence  of  secretion,  as  these 
tumors  in  the  great  majority  of  cases  are  due  to  more  deep-seated 
affections. 

ffv,^*^  ?-'7^"  tb®  right  half  of  the  nose  it  is  possible  to  obtain  a  view 
ot  the  middle  nasal  meatus  above  the  narrow  inferior  turbinate.  Corre- 
sponding to  the  lower  boundary  of  the  middle  meatus  is  seen  the  dark 
posterior  wall  of  the  pharynx,  while  above  is  a  prominent  red  tumor, 
hemispheric  in  .shape,  and  built  up,  as  it  were,  in  two  terraces.  The 
upper  portion  corresponds  to  the  anterior  extremity  of  the  middle  tur- 
binate, while  the  lower  portion  (m!)  shows  in  perspective  the  lower  por- 
tions of  the  same  turbinate,  which  are  also  enlarged.  From  the  color 
and  other  appearances  of  the  mucous  membrane,  however,  it  is  seen  at 
once  that  we  have  to  deal  not  with  a  heterologous  tumor,  but  with 

Hypertrophy  of  the  Middle  Turbinate. 


PLATE  28  {Ckmtinued). 

On  the  left  side  we  see  the  anterior  extremity  of  the  lower  turbinate 
converted  into  a  spheric  mass  of  swollen  tissue.  The  surface  is  smooth, 
and  the  hypertrophy  occludes  the  inferior  and  part  of  the  middle  nasal 
meatus. 

Hypertrophy  of  the  Anterior  Extremity  of  the  Inferior 
Turbinate. 

(The  pale-red,  wedge-shaped  areas  above  the  choanse  correspond  to 
mucous  membrane  of  the  ala;  nasi,  which  is  compressed  by  the  sjieculum 
and  consequently  bloodless  and  pale  in  color.) 

Fig.  3. — A  wide  view  of  the  interior  of  the  nose  is  presented.  Owing 
to  the  great  distance  between  the  middle  turbinate  (wi)  and  the  outer 
wall  of  the  nose  a  much  larger  portion  of  the  middle  meatus  (h)  is  vis- 
ible than  in  ordinary  cases.  Above,  the  meatus  forms  a  sharp  angle 
between  the  middle  turbinate  and  the  outer  wall  of  the  nose.  This 
angle  is  bounded  below  by  an  arciform  fold.  The  approximately  cres- 
centic  area  represents  the 

Entrance  to  the  Frontal  Sinus. 

It  is  only  in  rare  instances  that  it  can  be  seen  as  plainly  as  in  this 
picture. 

The  remaining  letters  stand  for  the  following  structures  :  r,  posterior 
pharyngeal  wall ;  m',  lower  surface  of  the  middle  turbinate  seen  in  pro- 
file ;  u',  median  surface  of  the  lower  septum  seen  in  profile ;  s,  septum. 

Fig.  4. — In  the  left  half  of  the  nose  a  large  portion  of  the  posterior 
wall  of  the  pharynx  is  seen  through  the  choana,  while  the  outlook  is 
bounded  on  the  median  side  by  the  septum  (a),  below  by  the  inferior 
turbinate  (6),  and  to  the  outer  side  by  the  anterior  surface  of  the  tubal 
fold.  Above  the  upper  margin  of  the  choana  there  is  seen  a  roundish, 
cup-shaped  depression  (d)  with  a  sharply  defined  border,  and  lined  with 
yellowish  mucous  membrane  ;  it  is  encroached  upon  below  by  the  middle 
turbinate  (c),  which  is  very  much  contracted.  This  depression  rep- 
resents the 

Left  Sphenoid  Sinus. 

The  sinus  is  greatly  enlarged  as  a  result  of  an  old  suppuration,  and 
therefore  visible  in  so  unusually  large  an  extent.  Below  the  middle 
turbinate  several  smaller  depressions  (e)  of  similar  appearance  are  seen. 
They  represent  cells  in  the  ethmoid  bone  where  a  similar  suppurative 
process  has  been  at  work. 


Tah.2S. 


Fill  i 


Fig.^. 


tC(f.J. 


Fig.  4-. 

Lith,  Anst  F.  RpirhlwUI  Miinrhen . 


'rah.L\9. 


Fig.l. 


Fig.  2. 


FigJ. 


PLATE  29. 

Fig.  1. — In  this  patient  both  middle  turbinates  had  been  almost 
entirely  removed  on  some  former  occasion.  At  the  present  time  two 
splieric  openings  {S )  are  seen  above  the  right  choana.  They  repre- 
sent the  artificial  orifices  of  two  ethmoid  cells.  On  the  left  side,  on  the 
remains  of  the  middle  turbinate,  there  is  a  cleft  (St),  deeper  above  than 
below — the  opening  of  the  frontal  sinus. 

Fig.  2. — A  gentleman,  forty-two  years  of  age,  is  subject  to  frequent 
headache.  From  the  left  side  of  the  nose  plugs  of  mucus  are  con- 
stantly expelled,  especially  in  the  morning. 

The  anterior  extremity  of  the  middle  turbinate  is  apparently  double ; 
it  is  thickened,  and  the  surface  at  that  point  is  somewhat  redder  than 
elsewhere,  and  presents  an  irregular,  granular  appearance.  Above  this 
somewhat  club-shaped  swelling  there  is  seen  a  narrow,  oval  cleft,  the 
recessus  meatus  medii,  which  in  this  case  is  exceptionally  distinct.  On 
further  examination  it  is  found  that  this  is  the  origin  of  the  secretion, 
and,  as  the  jaw  as  well  as  the  frontal  sinus  can  be  excluded  as  possible 
sources,  the  diagnosis  of 

Circumscribed  Catarrh  of  the  Middle  Meatus 

is  arrived  at. 

Fig.  3. — After  careful  spraying  and  maceration,  several  offensive 
gravish-red  crusts  are  removed  from  the  right  half  of  the  nose. 

After  waiting  a  short  time,  the  entire  surface  of  the  inferior  turbi- 
nate appears  covered  with  a  number  of  small  yellow  drops  of  pus,  the 
intervening  mucous  membrane  being  dry  and  rather  pale. 

The  picture  corresponds  to  what  is  sometimes  called 

"Ozena." 

The  secretion,  which  in  this  case  comes  from  the  antrum,  foi-ms  a  thin, 
uniform  laver  and  becomes  arrested  by  the  projecting  portions  of  the 
mucous  membrane,  where  it  collects  to  form  drops  which  gradually 
enlarge  sufficiently  to  be  seen. 


PLATE  30. 

Fig.  1. — A  woman,  forty-two  years  of  age,  has  noticed  a  dryness  ia 
the  uose  for  about  a  year.  There  is  also  a  feeling  of  tension,  so  that  she 
is  constantly  scratching  her  nose  and  sometimes  makes  it  bleed.  The 
patient  has  always  had  the  habit  of  scratching  her  uose,  but  the  habit 
has  increased  since  her  husband's  death.  "  Of  what  did  he  die,  and 
when?"     "Of  pulmonary  disease;  six  months  ago." 

The  anterior  portion  of  the  septum  in  the  right  half  of  the  nose  is 
covered  with  small,  flat,  spheric,  grayish-red  prominences,  which  grad- 
ually subside  toward  the  posterior  part  of  the  nose,  where  they  merge  with 
the  healthy  mucous  membrane  ;  they  also  extend  laterally  over  tlie  floor 
of  the  nose  and  to  the  anterior  end  of  the  inferior  turbinate.  The  chief 
localization  is  on  the  crest  of  the  septum. 

The  starting-point  of  the  disease  then  awakes  a  suspicion  of 

Tuberculosis  of  the  Nares, 

a  diagnosis  that  finds  support  in  the  nodular  appearance  of  the  lesions 
and  diffuse  distribution  of  the  proce-ss. 

Inspection  is  supplemented  by  palpation,  which  shows  that  the  struc- 
tures are  of  a  hard  consistency,  with  a  great  tendency  to  bleed,  and  the 
diagnosis  is  finally  confirmed  by  microscopic  examination,  especially  of 
the  histologic  structure,  since  bacilli  are  often  not  to  be  found.  Infec- 
tion is  readily  traced  by  the  history. 

Fig.  2. — For  purposes  of  comparison  we  have  here  given  the  picture 
of  a  small,  circumscribed,  sessile  tumor  on  the  septum,  resembling  a 
strawberry,  and  pale  red  in  color.     It  is  a 

Papilloma  of  the  Septum. 

This  picture  well  illustrates  the  difierence  between  this  benign  neo- 
plasm, with  its  sharp  limitation  and  uniform  growth  of  the  individual 
papillary  elements,  and  the  tuberculous  infiltrate,  which  is  ill  defined 
and  blurred  and  shows  no  distinct  delimitation,  but  which  is  always 
characteristic,  no  matter  how  much  it  may  assume  the  appearance  of  a 
tumor. 

Fig.  3. — A  young  woman,  twenty-two  years  of  age,  complains  of 
violent  headache,  especially  in  the  frontal  region,  for  the  past  four  days. 
There  is  also  marked  obstruction  of  the  nose. 

The  nose  itself  appears  to  be  fairly  free.  The  nasopharynx  presents 
a  moderately  thick  layer  of  adenoid  tissue.  The  diagnosis  remains  in 
doubt. 

Four  days  later:  The  inferior  turbinate  on  the  right  side  is  slightly 
swollen.  After  the  application  of  cocain  the  headache  diminishes,  and 
disappears  entirely  after  the  entire  septum  has  been  painted  with  cocain. 
On  the  following  day  the  improvement  continues,  but  on  the  day  after 
that  the  pain  returns.  A  small  crust  of  dried  pns  is  now  found  on  the 
anterior  surface  of  the  inferior  turbinate;  opposite  the  lower  portion  of 
the  septum  the  middle  turbinate  is  also  somewhat  thickened.  After  the 
crust  on  the  septum  has  been  removed,  the  latter  appears  slightly 
wrinkled  and  irregular,  with  a  moderate  retraction  at  the  center.  On 
being  questioned  the  patient  states  that  the  hair  of  her  head  is  rapidly 
dropping  out.  Her  social  standing  is  such  as  to  forbid  more  inquisitorial 
questions,  but  the  clinical  picture  is  so  suspicious  that  potassium  iodid 
appears  to  be  indicated. 


PLATE  30  {Cbntinued). 

Four  days  later:  the  wriukling  of  the  septum  is  more  pronounced 
than  on  the  last  visit;  tlie  central  retraction  hai  extended  from  behind 
forward.     The  headache  has  now  completely  disappeared. 

Three  days  later  the  following  unequivocal  condition  is  found  : 

Marked  swelling  of  the  middle  and  inferior  turbinates  on  the  right 
side.  The  inferior  turbinate  presents  an  irregular  ulcer,  the  floor  of 
which  is  covered  with  a  lardaceous  exudate  and  surrounded  by  an  exten- 
sive area  of  injection.  This  ulcer  is  continuous,  by  way  of  the  floor  of 
the  nose,  with  another  ulcer  in  every  respect  similar  to  it  on  the  septum. 

A  third,  somewhat  shallow,  but  very  extensive  ulcer  of  similar 
appearance  and  more  distinctly  sinuous  outline  occupies  the  middle 
turbinate. 

On  the  floor  of  the  septal  ulcer  the  probe  comes  upon  rough  bone ; 
everywhere  the  tissues  bleed  at  the  slightest  touch. 

A  single  glance  would  now  suftice  to  establish  the  diagnosis  of 

Tertiary  Syphilitic  Ulcers. 

The  picture  of  the  left  half  of  the  nose  represents  the  residuum  of  a 
similar  process,  an  old  perforation  and  a  cicatrix  with  loss  of  tissue  of 
the  middle  turbinate. 

Fig.  4. — The  floor  of  the  nose  and  the  adjacent  portions  of  the  infe- 
rior turbinate  and  of  the  septum  are  intensely  red.  Within  this  zone 
there  is  a  grayish-white  exudate,  apparently  on  a  level  with  the  mucous 
membrane.  The  middle  nasal  meatus,  the  middle  turbinate,  and  the 
septum  are  covered  with  yellowish-gray  masses  of  pus. 

These  collections  of  pus  attest  the  intense  reaction  of  the  entire  nasal 
mucous  membrane  to  the  inflammatory  process  going  on  in  the  anterior 
segment.  The  exudative  nature  of  this  process  is  recognized  by  the 
appearance  and  by  means  of  the  probe,  which  shows  the  wide  patches 
to  be  tenacious  but  removable  membranes.  The  inflammation  is  there- 
fore a 

Fibrinous  Rhinitis. 

[While  fibrinous  rhinitis  is  a  distinct  pathologic  possibility,  the  bacterio- 
logic  experience  of  recent  years  has  shown  that  many  cases  presenting  the 
appearance  described  are  in  reality  nasal  diphtheria.  Tliis  variety  of  the 
disease  was  formerly  regarded  as  one  of  its  most  malignant  manifestations, 
but  in  many  cases  in  which  the  culture-test  reveals  the  presence  of  the  Klebs- 
Liiffler  bacillus,  the  constitutional  and  local  symptoms  are  mild  and  the 
patient  not  very  ill,  recovering  without  any  special  aifliculty.  Various  micro- 
organisms can  cause  here,  as  elsewhere,  a  membranous  exudate.— Ed.] 


Tab.. 30. 


Fiff.1. 


Fig.  2. 


Fig.3. 


Fig.  4^. 


Lith  Amt  F.  ReLMwld.  Miinchen. 


Tab.:il. 


.•>-*-r>rasW5i^^^Sifes»., 

%^.. 

/ 

''  .. 

'  U ^' 

1  ,  .  ,  ,  _  .- 

.-  '- 

l^jlr           ' 

wMM" 

''  ^m 

$p^. 

' 

■■^/v::- 

IJ- r'tfi^  i    ' u 

FiffJ. 


LUfi.  Anst.t:  ReixJihold.  Muiichen. 


Fig.J. 


PLATE  31. 
Fig.  1.— Sagittal   Section  of  the  Hyperplastic  Pharyngeal 
Tonsil  from  a  Child  (  xl7). 

The  tissue  is  almost  entirely  made  up  of  various  sized  lymph- 
follicles.  The  loose-raeshed  intervening  tissue  consists  largely  of  round- 
cells.     A  few  blood-vessels  appear  near  the  base. 

Fig.  2.— The  Same  Tumor  from  an  Adult  (x21). 

The  marginal  zone  of  the  follicles  has  a  greater  density.  The  fol- 
licles are  scattered  in  the  stroma,  which  is  traversed  by  numerous 
capillaries  and  strengthened  by  connective-tissue  trabeculae  of  varying 
thickness.     The  picture  represents  the  stage  of  involution. 

Fig.  3. — Frontal  Section  of  a  Pharyngeal  Tonsil  (x53). 

Above,  the  remains  of  lymphadenoid  tissue  are  shown.  The  remain- 
ing poi'tion  presents  three  partially  closed  cavities,  surrounded  by  thin 
layers  of  similar  tissue,  without  any  especial  alteration  in  the  walls. 
These  cystoid  cavities  were  undoubtedly  produced  by  inflammatory 
degeneration  of  follicles. 


PLATE  32.- 

FiQ.  1.— This  represents  a  pharyngeal  tonsil  already  in  advanced 
condition  of  involution.  Near  the  median  line  there  Ls  a  deep  cleft, 
which  becomes  wider  toward  the  Ixise — a  pharyngeal  bursa.  Tlie 
section  presents  on  the  left  side  and  below,  the  surface  of  tlie  tonsil ; 
on  the  right  side  and  above,  the  inner  wall  of  the  cleft.  The  inter- 
vening layer  exhibits  the  type  of  lyinphadenoid  tissue  in  process  of 
involution  (see  Plate  81,  Fig.  2).  At  one  point  the  tissue  rises  to  form 
a  villous  process,  wliich  almost  touches  the  basal  wall,  so  that,  if  the 
growth  shoidd  continue,  the  epithelial  surfaces  would  come  in  contact 
with  one  another  and  break  down,  with  the  production  of  a  closed 
cavity  or  cyst  The  epithelium  on  these  surfaces  is  in  places  greatly 
hypertrophied,  and  has  undergone  an  epiderinoidal  change,  while  that 
of  the  inner  surface  has  preserved  the  type  of  cylindric  cells  arranged 
in  a  single  layer  (  x  18). 

Rq.  2. — Small,  Soft,  Pedunculated  Tumor,  Growing  from 
the  Upper  Surface  of  One  of  the  Palatal  Tonsils  (  x  9). 

The  right  wall  is  formed  by  a  thin  strip  of  connective  tissue,  while 
the  left  wall,  toward  the  inner  side,  consists  of  the  remains  of  tonsillar 
tissue,  and,  on  the  outer  side,  of  a  more  homogeneous  fibroid  tissue, 
deficient  in  cellular  elements  and  containing  only  a  few  spai-se  remains 
of  cells.  The  outer  and  inner  walls  of  the  cyst  are  covered  by  cylindric 
epithelium,  in  part  laminated,  making  it  obvious  that  the  cavity  could 
have  been  produced  only  by  the  union  and  cohesion  of  diflerent  por- 
tions of  the  surface  of  the  tonsil. 

Fig.  3. — Section  of  the  tumor  represented  in  Fig.  3  of  Plate  26, 
being  a  juvenile  sarcoma.  lielow  the  surface,  a  few  lymph-follicles 
with  a  border  of  densely  aggregated  cells  are  observed.  The  remaining 
tissue  consists  of  loosely  arranged  round-cells  with  an  enormous  vasculax 
development,  explaining  the  rapid  growth  (xl2). 


Tob..rj. 


Fig.J. 


LUh.  Anst  t:  RMchiwld.  Miincheti. 


Tab..Vi. 


Fiq.l. 


■iB»««f**- 


i^^fvi?:- 


W' 


'^  -^^s^ 


LUh.  AnstK  Reichhald.  Muiuhen.  '^  '^' 


PLATE  33. 

Fig.  1.— Section  of  Smooth,  Club=shaped  Hypertrophy  of 
the  Anterior  Extremity  of  the  Inferior  Turbinate  (xl2.5). 

Below  the  slightly  wavy  surface  there  is  a  narrow  layer  of  connective 
tissue,  infiltrated  with  round-cells.  For  the  rest  the  entire  body  of  the 
tumor  is  occupied  by  dilated  veins  with  thick  walls  representing  a  hyper- 
plnsia  of  the  corpus  caveniosum.  Here  and  there  arteries  surrounded  by 
an  intense  inflaiuniatory  proliferation  are  seen.  Around  the  periphery 
numerous  smaller  vessels  pass  to  the  surface. 

Fig.  2. — Combination  Picture  from  a  Mucous  Polyp  (  x90). 

(The  stroma  is  narrower  in  the  picture  than  in  reality,  and  the 
glands  and  vessels  therefore  appear  crowded  together  in  a  smaller  space. ) 

The  foundation  consists  of  loose,  connective  tissue  composed  of  ex- 
tremely thin  fibers,  reinforced  by  elastic  fibers,  and  very  poor  in  cells. 
Below  is  seen  a  coil  of  dilated  glands.  The  gland  on  the  right  side  has 
degenerated  into  a  spiral  tube,  and  the  surrounding  tissue  is  infiltrated 
with  small  cells.  The  smaller  vessels  near  the  center  of  the  section 
(cut  longitudinally)  present  endo-  and  peri-arteritic  proliferations.  The 
same  condition  is  observed  in  the  larger  arteries,  in  which  the  lumen  is 
almost  completely  occluded  by  the  round-cells.  In  the  large  veins 
above  and  on  the  left-hand  side  of  the  picture  there  is  a  conspicuous 
thickening  of  the  intima,  suggesting  trabeculae,  with  great  naiTowing  of 
the  lumen. 

The  constriction  in  the  vessels  explains  the  development  of  edema 
in  tissues  of  this  character. 


PLATE  34. 

Pale-red,  Slightly  Bosselated  Tumor  on  the  Anterior  Ex- 
tremity of  the  Inferior  Turbinate  (  x  10). 

The  loose-meshed  tissue,  which  is  traversed  by  a  number  of  blood- 
vessels, is  moderately  rich  in  cells,  and  contains  four  large  cavities  and 
a  number  of  smaller  ones.  The  inner  walls  of  these  cavities  are  lined 
partly  with  a  single  layer  of  squamous  epithelium,  and  partly  with 
cylindric  cells,  arranged  in  a  single  or  in  several  layers.  The  lumen 
of  one  of  the  cavities  is  encroached  upon  by  sevenil  broad  papillae, 
while  the  lumen  of  another  is  invaded  by  infiltrated  connective  tissue. 

The  cavities  have  been  formed  by  dilated  glands,  and  the  mass  is 
to  be  designated  a  cystadenoma. 


7ab.:i^. 


Lith.  AnsI  F-  Reichhold.  Miiivchejt . 


Ihh.iS. 


^•iN-^ix.agr 


J>y.7. 


Eig.^. 


l.Uh.  Anst  I-'  ReicMwld .  Maiuhen.. 


PLATE  35. 

Fig.  1.— Part  of  a  Section  of  a  Pale=red  Tumor  from  the 
Anterior  Extremity  of  the  Middle  Turbinate  (xl3). 

The  tumor  is  almost  exclusively  composed  of  roundish  coils,  the 
integral  parts  of  which,  under  higher  magnification,  reveal  themselves. 
The  scanty  intei-stitial  tissue  is  almost  entirely  composed  of  blood- 
vessels. On  the  right  side  and  above  there  is  a  dilated  artery  with 
thickened  and  infiltrated  walls :  adenoma. 

Fig.  2.— Part  of  a  Cauliflower  Tumor  from  the  Middle 
Turbinate  (xl9). 

The  surface  is  covered  by  cylindric  epithelium,  in  places  greatly 
hypertrophied.  Within  the  supporting  tissue,  which  is  poor  in  cells, 
there  are  a  number  of  approximately  oval  depositions,  consisting  exclu- 
sively of  epithelium.  In  the  central  portion  of  the  tumor  the  cells  are 
degenerated  (loss  of  nuclear  pigmentation). 

We  evidently  have  to  deal  with  atypical  proliferation  of  the  surface 
epithelium  into  the  deeper  strata,  accompanied  by  papillary  hyper- 
trophy of  the  connective  tissue.  It  is  a  malignant  papillary  fibro-epi- 
thelioma,  malignant  because  in  its  growth  it  has  broken  up  and 
destroyed  normal  tissue. 


PLATE  36. 

Fig.  1. — An  extremely  friable  tumor  with  a  great  tendency  to  bleed, 
taken  from  the  edge  of  a  middle  turbinate,  which  liad  been  destroyed 
by  a  syphilitic  ulcer.  The  single  layer  of  cylindric  epithelium  is  in 
places  capped  by  a  thin,  amorphous  layer  containing  isolated  round- 
cells.  In  the  upper  portion  the  epithelium  is  wanting  and  the  tissue 
itself  presents  a  deep,  sharply  defined,  somewhat  undermined  defect. 
The  ground-substance  is  composed  of  a  cellular  network  containing 
numerous,  and  in  part  greatly  dilated,  veins,  which  lend  to  the  entire 
mass  a  spongy  appeai-ance.  Towai-d  the  periphery  there  is  a  more 
compact  infiltration  of  round-cells  without  blood-vessels,  which  on  the 
left  side  and  above  extends  in  the  form  of  papillse  into  the  scanty-celled 
tissue.  Below,  there  is  a  roundish  accumulation  of  cells  presenting 
central  softening: 

Qummatous  and  Diffuse  Syphilitic  Hyperplasia  ( x  11). 

Fig.  2. — Pale-red,  slightly  bosselated,  soft  tumor  from  the  lower  sec- 
tion of  the  wall  of  the  nasal  septum,  removed  with  a  snare.  The  tumor 
consists  almost  entirely  of  small  round-cells  arranged  in  more  or  less 
distinct,  chiefly  spheric  and  oval  nests,  the  central  portions  of  which 
are  characterized  by  a  deficiency  of  the  nuclear  stain  and  contain  small 
blood-vessels.  On  the  right  and  below  three  smaller  aggregations  (R) 
are  visible,  which,  under  higher  magnification,  reveal  themselves  as 
giantrcells  containing  an  enormous  number  of  nuclei.  The  tubercular 
nature  of  the  large  conglomeration  ( T )  therefore  clearly  establishes : 

Tuberculous  Tumor  of  the  Septum  (  x  30). 


^'     %_    ;:■:■ 


"^»iii?-Y-^ 


_>.r4^       3 


^ 


Fi(/J. 


J  a. 


) 


/I 


Fig.  2. 


Lith.  Anst  F.  Reictthold,  Miinchen . 


Tab.J?. 


•fsf-?. 


LUh.  AnsL  /■:  ReiOthold,  Miinrhen. 


PLATE  37. 

Fig.  1. — Central  portion  of  a  section  through  the  wall  of  a  bone 
cyst  in  the  middle  turbinate  (see  p.  105),  which  was  filled  with 
pus  and  exhibited  polypoid  degeneration  of  the  mucous  membrane  on 
its  outer  and  inner  walls. 

The  center  of  the  section  is  formed  by  the  bone,  the  continuity  of 
which  in  two  places  is  interrupted  by  softer  tissue.  The  patch  on  the 
right  is  a  spheric  collection  of  cells  bounded  in  every  direction  by 
bone.  On  the  left-hand  side  the  opposite  layers  of  the  periosteum  are 
connected  by  a  bridge  of  tissue.  The  bone-corpuscles  surrounding  the 
collection  of  cells  present  a  different  arrangement  from  that  observed 
in  the  rest  of  the  bone,  and  by  their  size,  irregular  shape,  and  nuclear 
proliferation,  declare  themselves  as  osteoclasts. 

Near  the  periosteum  similar  transitional  cells  are  seen.  The  adja- 
cent tissue  is  studded  with  masses  of  cells,  due  to  active  proliferation 
of  round-cells,  which  in  the  upper  portion  of  the  picture  completely 
disguise  the  true  structure  of  the  periosteum. 

Two  processes  are,  therefore,  at  work :  destruction  of  bone  and  con- 
vereion  of  bone  into  connective  tissue  by  inflammatory  proliferation 
(x420). 

Fig.  2. — Transverse  section  of  a  middle  turbinate  in  antrum  disease. 
The  median  surface  of  the  turbinate  was  occupied  by  an  ulcer. 

The  bone  of  the  turbinate  in  the  section  is  largely  replaced  by  con- 
nective tL<sue.  The  mucous  membrane  of  the  median  surface  (above) 
everywhere  presents  marked  inflammatory  infiltration,  and  in  the  middle, 
an  ulcer  extending  into  the  submucosa  and  undermining  the  tissue  on 
each  side. 


PLATE  38. 

P^G.  1. — In  a  case  of  suppuration  of  the  frontal  sinus  a  rovgh,  worm- 
eaten  area  was  felt  on  the  outer  surface  of  the  middle  turbinate  in  the 
right  half  of  the  nose.  At  this  point  a  deep  ulcer,  extending  to  the 
bone  and  surrounded  by  ragged  tissue,  was  discoveied.  The  bone  at 
this  point  and  here  and  there  at  a  deeper  level  imperceptibly  merges 
into  connective  tissue  or  giunulation  tissue.  The  entire  mass  is  so  infil- 
trated with  round-cells  as  to  be  practically  unrecognizable.  On  the 
surface  the  nuclei  can  barely  be  made  out : 

Superficial   Ulcer  with  Granulating  and    Rarefying  Osteitis. 

Fig.  2. — A  middle  turbinate  in  a  case  of  suppuration  of  an  acces.sory 
cavity,  with  a  broad  supei"ficial  ulcer  and  exposed  worm-eaten  bone. 

The  bone  in  the  middle  is  completely  bared  and  raised  into  a  spheric 
prominence.  On  the  surface  and  at  various  points  in  the  depths  of  the 
tissue  it  fades  away  into  fibrillar  and  round-celled  tis.sue.  The  lateral 
portions  are  still  covered  with  greatly  thickened  and  infiltrated  perios- 
teum. Only  on  the  extreme  right  it  is  covered  by  a  similarly  inflamed 
and  altered  granular  layer  of  mucosa.  On  the  other  side  the  bone 
breaks  up  into  trabeculae  forming  various  hollow  spaces : 

Granulating,    Hyperplastic,  and    Rarefying  Osteitis  Under- 
neath an  Ulcer  Involving  the  Entire  Thickness  of 
the  Mucous  Membrane. 


Fig.Ji. 


LUh.  Anst  F.  ReijChhold,  Uiinchjen . 


Tab. 3  9. 


'■.'A 
'<i'.:~. 


■.'':'.i 


•  •".     .■.;V;f^<.,.»V,-.V..''        •     J.': 

■'  ■;•'    .-<■'?■■ '-Av*^'' '■       .   •  P' 


PLATE  39. 

Grayish-red  polypoid,  sessile  tumor  from  a  middle  turbinate; 
the  adjacent  ethmoid  cells  were  destroyed  by  the  suppurative 
pi'ocess. 

The  ground-substance  of  the  tumor  is  formed  by  a  loose-meshed 
reticular  tissue  composed  of  round-cells,  and  containing  within  its 
meshes  finely  granular,  structureless  masses — coagulated  dropsical  fluid 
(edema).  Toward  the  base  the  density  of  the  tissue  increases,  and 
there  are  numerous  minute  blood-vessels,  while  in  the  peripheral  por- 
tion they  are  very  sparingly  present.  The  surface  is  covered  with 
cylindric  epithelium,  some  parts  are  smooth,  while  othere  are  raised  to 
form  minute  papillae  which  often  present  a  villous  appearance.  The 
left-hand  portion  is  travei"sed  by  a  dense  infiltration  of  round-cells  par- 
allel to  the  surface ;  at  one  point  the  round-cells  are  aggregated  around 
a  gland  and  simulate  a  follicle.  We  accordingly  have  to  do  with  pro- 
liferation of  the  mucous  membrane  in  the  form  of 

Edematous  Fibroma  with  Inflammatory  Infiltration  ( x  20). 


PLATE  40. 

Slightly  Lobulated,  Dark-red  Tumor  from  the  Anterior 
Extremity  of  an  Inferior  Turbinate  (  x  21 ). 

The  interior  of  the  tumor  presents  several  veins  from  the  erpctile 
tissue  of  the  turbinate ;  the  walls  of  some  of  the  veins  are  hypertro- 
phied.  Overlying  this  sti-atum  is  a  dense  mass  of  connective  tissue 
with  a  reticulated  growth  of  round-cells.  The  epithelium  is  hyper- 
trophied  at  almost  every  point.  In  some  places  it  is  arranged  in  massive 
layers,  and  forms  processes  which  at  one  point  are  mingled  with  greatly 
infiltrated  glands  and  extend  to  a  great  depth.  The  entire  surface, 
including  the  epithelium,  is  infiltrated  with  round-cells. 


Tad.40. 


^M'VI 


TohAI. 


Fiff.l. 


Fiff.3. 


PLATE  41. 

Fig.  1. — Lobulated,  Qrayish=red,  Sessile  Tumor  from  the 
Anterior  Portion  of  an  Inferior  Turbinate  ( x  15). 

Eemains  of  erectile  and  glandular  tissue  are  found  only  in  the 
middle  of  the  tumor.  The  rest,  especially  near  the  surface,  consists 
almost  entirely  of  cellular  connective  tissue  containing  slightly  thick- 
ened blood-vessels,  and  drawn  out  in  places  into  papillae  of  varying 
sizes.  The  covering  consists  almost  exclusively  of  a  single  lajer  of 
cylindi-ic  epithelium : 

Soft  Papillary  Fibroma. 

Fig.  2. — Hard,  Smooth,  Dark-red  Tumor  from  the  Anterior 
Extremity  of  an  Inferior  Turbinate  (  x  15). 

Barring  tlie  surface,  where  the  cellular  element  is  fairly  well  repre- 
sented, the  entire  tumor  is  practically  made  up  of  small  arteries ;  at  the 
center  a  few  remains  of  the  cavernous  plexus  of  veins  are  seen : 

Angiofibroma. 


PLATE  42. 

Grayish-red  tumor  of  rapid  growth,  removed  from  the  vestibule  of  a 
girl  four  and  one-half  years  old  (the  tumor  probably  grew  from  the 
middle  turbinate). 

Loose,  spongy  tissue  traversed  by  open  spaces  of  varying  size  and 
shape.  The  spaces  consist  of  dilated  blood-vessels,  the  walls  of  which 
are  formed  directly  by  the  cells  of  the  structure. 

Under  a  higher  magnification  the  entire  tumor  appears  to  consist 
chiefly  of  round-cells  containing  a  delicate  intercellular  substance. 
These  cells  grow  from  the  inner  and  outer  walls  of  the  larger  blood- 
vessels, and  form  within  the  apparently  avascular,  more  compact  areas 
a  network,  the  meshes  of  which  represent  blood-spaces  without  walls : 

Angiosarcoma. 


Tab.'^2. 


iJ^ 


PRELIMINARY  REMARKS  ON  ANATOMY 
AND   PHYSIOLOGY. 


The  pharyugo-oral  cavity  may  be  regarded  as  the  first 
portion  of  the  digestive  tract,  charged  with  the  duty  of 
preparing  the  food  for  digestion.  As  it  is  intercalated  in 
the  course  of  the  air-passage,  which  intersects  the  diges- 
tive tract,  the  only  true  pharyngeal  portion  is  the  so-called 
pars  oralis  or  intermediate  portion,  also  known  as  the 
mesopharynx ;  the  lower,  laryngeal  portion,  or  hypo- 
pharynx,  belonging  to  the  larynx,  and  the  upper,  nasal 
portion,  or  nasopharynx,  to  the  nasal  cavities.  The 
pharyngo-oral  cavity  proper,  therefore,  is  bounded  in 
front  by  the  lips  ;  behind  by  the  cervical  portion  of  the 
vertebral  column  and  overlying  muscles ;  above  by  the 
hard  and  soft  palate  and  by  an  imaginary  plane  drawn 
through  the  pharyngeal  cavity  to  the  vertebral  column  at 
the  level  of  the  hard  palate  ;  below  by  another  imaginary 
plane  at  the  level  of  the  superior  aperture  of  the  larynx, 
coinciding  with  the  upper  surface  of  the  epiglottis.  In 
front  the  pharyngo-oral  cavity  communicates  with  the 
extremely  irregular  basin  formed  by  the  soft  parts  of  the 
floor  of  the  mouth.  Laterally,  the  pharynx  is  bounded 
by  the  cheeks  and  the  inner  surfaces  of  the  deep  muscles 
of  the  neck. 

It  is  only  during  the  act  of  deglutition  that  the  posterior 
boundary  of  the  oropharynx  is  clearly  defined,  for  during 
that  act  the  epiglottis  shuts  off  the  larynx  ;  the  soft  palate 
is  raised  and  forced  against  the  structures  at  the  back  of 
the  cavity,  so  as  to  shut  off  the  nasopharyngeal  space. 

It  is  important,  in  order  to  understand  the  histology 
as  well  as  the  neoplasms  of  the  oropharynx,  to  know  that 

1 


2  PRELIMINARY  REMARKS  ON 

most  of  the  parts  of  the  raoutli  proper — namely,  the  lower 
jaw,  the  soft  parts  of  the  cheeks,  the  palate,  as  well  as 
the  anterior  half  of  the  tongue,  which  first  makes  its 
appearance  as  a  mesial  node  at  the  symjjhysis  of  the  man- 
dibles— develop  from  the  first  branchial  arch ;  while  the 
derivatives  of  the  second  branchial  arch,  advancing  from 
behind  forward,  help  to  form  the  pharynx  proper  and  the 
posterior  half  of  the  tongue.  The  lower  boimdaries  of 
these  two  developmental  portions  form  a  triangle  that  is 
open  posteriorly ;  immediately  below  is  the  rudiment  of 
the  superior  thyroid  gland,  the  remains  of  which  persist 
during  extra-uterine  life,  as  the  foramen  caecum  of  the 
tongue.  This  difference  in  the  mode  of  origin  of  the  two 
halves  of  the  mouth  explains  why  the  oral  cavity  is  lined 
and  the  anterior  half  of  the  tongue  is  covered  with 
squamous  epithelium  of  a  distinctly  epidermal  character, 
the  tongue  even  showing  papillae,  whereas  in  the  posterior 
parts  the  glandular  structures  predominate  and  the  epithe- 
lium shows  an  increasing  tendency  to  present  the  cylin- 
dric  mucous-membrane  type. 

The  deeper  layers  of  the  mucous  membrane  vary  in 
character  according  to  the  substratum.  Where  the  latter 
consists  of  soft  connective  tissue  made  up  of  long  fibers, 
the  mucous  membrane  is  able  to  follow  the  varying  move- 
ments of  the  muscle  layers  in  the  floor  of  the  mouth,  of 
the  cheeks,  and  of  the  soft  palate  without  any  difficulty. 
On  the  other  hand,  it  is  intimately  attached  to  the  bones 
of  the  upper  and  lower  jaws  by  means  of  short  bundles 
of  fibrous  tissue,  so  that  at  the  thinnest  portions  the  peri- 
osteum and  submucosa  imperceptibly  merge  into  each 
other.  In  regions  like  the  lips,  supplied  by  sphincters 
with  only  moderate  excursions,  the  connection  between 
the  muscle  and  the  mucous  membrane  is  so  close  that  the 
latter  is  forced  to  adapt  itself  to  the  changes  of  volume 
in  the  muscle  by  wrinkling.  These  anatomic  relations, 
which  harmonize  perfectly  with  the  greater  abundance  of 
fat  and  lymph  clefts  in  the  looser  layers  of  tissue,  cast  a 
light  on  the  spread  of  infection  downward.     It  is  only 


ANATOMY  AND  PHYSIOLOGY.  3 

necessary  to  call  to  mind  the  behavior  of  infiltrations  in 
the  spongy,  loose  structures  of  the  floor  of  the  mouth, 
their  marked  tendency  to  spread,  and  the  great  destruction 
of  tissue  that  they  are  apt  to  produce.  The  surface  of 
the  mucous  membrane  in  the  main  adapts  itself  to  the 
underlying  stratum ;  on  the  hard  palate,  however,  a 
number  of  transverse  ridges  are  formed  by  the  presence 
of  hard  strands  of  fibrous  tissue.  These  transverse  ridges 
unite  in  the  median  line  to  form  an  anteroposterior  ridge, 
known  as  the  raphe. 

Similar  structures  are  the  frenum,  or  bridle  of  the  tongue, 
a  fold  of  tissue  passing  from  the  posterior  alveolar  border 
over  the  floor  of  the  mouth  to  the  inferior  free  surface  of 
the  tongue,  and  two  other  bands,  known  as  the  frenufa 
labii,  running  parallel  to  the  former,  between  the  anterior 
alveolar  margin  and  the  inner  surface  of  the  lips,  and 
finally  the  frenulum  epiglottidis,  connecting  the  tongue 
and  epiglottis  at  the  back.  The  tissue  proper  of  these 
structures  belongs  to  the  submucosa,  and  is  covered  by 
smooth  mucous  membrane  which  is  not  included  within 
the  fold.  Hence  they  may  escape  if  the  mucous  mem- 
brane aifection  is  merely  superficial.  The  tonsils,  which 
consist  of  adenoid  (gland-like)  tissue,  do  not  possess  a  sub- 
mucosa, being  covered  merely  by  a  thin  layer  of  epithe- 
lium. In  this  respect  they  resemble  the  other  structures 
of  the  so-called  adenoid  pharyngeal  ring  or  lymphatic 
ring,  consisting  of  the  lingual  and  pharyngeal  tonsils, 
which  almost  appear  like  foreign  structures  inserted 
in  the  continuity  of  the  oronasal  cavity  and  pharynx — 
originally  a  single  structure. 

The  posterior  and  anterior  pillars  of  the  fauces  (plicae 
salpingopharyngese,  and  glossopharj'ngeae),  which,  so  to 
speak,  form  a  frame  around  the  tonsils,  are  supported  on 
each  side  by  a  bundle  of  muscle  tissue  projecting  into  the 
cavity — the  palatoglossus  and  palatopharyngeus  muscles. 
The  mucous  glands  are  most  numerous  in  the  looser  tissues 
in  which  they  are  imbedded,  and  sometimes  attain  the 
size  of  a  pea ;  quite  frequently  they  are  observed  on  the 


4  PRELIMINARY  REMARKS  ON 

surface  of  the  tongue  and  witliin  the  dense  connective 
tissue  that  occupies  the  intervals  between  the  ridges  of 
the  hard  pahite ;  and  they  also  exist  sparingly  in  the  pos- 
terior wall  of  the  pharynx. 

Structures  peculiar  to  the  mouth  are  the  salivary  glands  ; 
the  parotid  glands  that  empty  their  secretion  through  the 
duct  of  Steno  on  a  so-called  carmicle ;  the  sublingual 
glands,  which  form  the  conspicuous  transverse  ridge 
crossing  the  bridle  of  the  tongue  in  the  floor  of  the  mouth, 
and  the  ducts  of  which — namely,  the  sublingual  ducts  or 
ducts  of  Bartholin — empty  about  a  finger's-breadth  to 
one  side  of  the  point  of  intersection  near  or  in  conjunc- 
tion with  those  of  the  submaxillary  glands  or  ducts  of 
Wharton ;  the  small  glands  of  Blandin  or  Nuhn  on  the 
lower  surface  of  the  tip  of  the  tongue ;  and,  finally,  the 
rudimentary  incmve  glandule.  Sometimes  the  sublingual 
gland  possesses  a  number  of  small  ducts — the  duets  of 
Rivinus — which  empty  behind  the  sublingual  caruncle. 

The  lymph-vessels  of  the  oropharynx  empty  their  con- 
tents into  a  number  of  glands,  the  submaxillary,  sub- 
mental, cervical,  and  jugular  glands,  of  which  the  first  two 
are  the  most  important.  In  the  case  of  circumscribed 
swellings  it  is  possible  to  locate  the  causal  irritation  in 
the  region  from  which  the  corresponding  afferent  vessels 
take  their  origin. 

The  follicle^,  both  solitary  and  agminated, — i.  e.,  col- 
lected in  denser  groups, — that  are  found  in  the  pharyn- 
geal mucous  membrane  and  within  the  palatal  mucosa  are 
also  of  lymphatic  nature  and  form  the  true  substratum 
of  the  lymphatic  ring  (Plate  31,  Fig.  1).  The  embryonal 
character  of  these  structures  is  shown  by  the  fact  that  they 
normally  undergo  involution  during  adolescence  and 
become  reduced  to  mere  rudiments,  as  also  by  their  ten- 
dency to  excessive,  although  not  atypical,  growth.  The 
capacity  of  these  structures  to  undergo  alteration  is  one 
of  the  most  important  among  the  fundamental  pathologic 
principles  in  this  region  of  the  body. 

The  blood-supply  is  efl'ected  by  branches  of  the  external 


ANATOMY  AND  PHYSIOLOGY.  5 

carotid  :  the  lingilal,  facial,  posterior  auricular,  temporal, 
and  internal  maxillary  ;  the  venous  blood  is  carried  oiF  in 
the  anterior  and  posterior  facial  and  lingual  veins,  and 
in  the  anterior  and  posterior  venous  plexuses.  For  the 
surgeon  the  most  important  vessels  are  the  tonsillar 
artery,  which  pierces  tlie  capsule  of  the  tonsils  in  such  a 
way  tiiat  it  may  be  prevented  from  retraction  if  it  chances 
to  be  injured,  and  thus  give  rise  to  hemorrhage ;  and  the 
i-anine  artery,  which  enters  the  muscular  tissue  of  the 
tongue  alongside  of  the  tonsillar.  Injury  of  this  vessel 
was  often  attended  with  danger,  especially  in  the  days 
when  the  practice  of  severing  the  frenum  linguae  was 
more  conmion. 

In  regard  to  the  nerves  of  the  oropharynx,  it  is  im- 
portant to  know  that  the  sensory  nerves  of  the  mouth 
and  tongue  are  branches  of  the  third  division  of  the  tri- 
geminal ;  those  of  the  pharynx  proper — the  posterior  or 
small  palatine  nerve — are  derived  from  the  second  divi- 
sion of  the  trigeminal  and  parts  of  the  glossopharyngeal. 
Gustatory  sensations  are  conveyed  by  fibers  of  the  glosso- 
pharyngeal and  the  chorda  tympani.  The  motor  innerva- 
tion of  the  tongue  is  effected  by  the  hypoglossal  nerve, 
that  of  the  muscles  of  mastication  by  the  third  division 
of  the  trigeminal,  and  that  of  the  lips,  of  the  uvula,  of  the 
levator  palati,  and  of  the  palatoglossus  and  palatopharyn- 
geus  muscles  by  the  facial  nerve.  The  tensor  palati  is 
controlled  by  the  third  division  of  the  trigeminal,  and 
the  superior  constrictor  of  the  pharynx  by  the  spinal 
accessory  nerve. 

The  functions  of  the  pharyngo-oral  cavity  include  articu- 
lation, mastication,  and  deglutition.  The  first  of  these  is 
effected  chiefly  by  the  position  of  the  lips  and  tongue, 
and  is  practically  confined  to  the  inside  of  the  mouth. 
Hence  inability  to  protrude  the  tongue  does  not  affect  the 
speech,  but  interference  with  lateral  and  vertical  move- 
ments of  the  tongue  results  in  indistinct  and  lalling  speech 
or  lallation.  Under  these  circumstances  deglutition  is  also 
impaired,  for  this  act  begins  with  elevation  of  the  tip  of 


6  PRELIMINARY  REMARKS  ON 

the  tongue,  a  movement  that  is  transmftted  in  vermicular 
fashio.n  along  the  entire  dorsum  of  the  tongue,  so  as  to 
force  the  bolus  gradually  downward.  In  order  that  the 
morsel  of  food  may  enter  the  esophagus,  the  oral  portion 
of  the  pharynx  must  be  shut  off,  at  least  for  an  instant, 
from  the  larynx  and  nasal  portions^ — in  other  words,  a 
continuous  digestive  tract  must  be  temporarily  supplied. 
This  is  effected  partly  by  forcible  elevation  of  the  base  of 
the  tongue,  completely  occluding  the  superior  aperture  of 
the  larynx,  and  partly  by  elevation  of  the  soft  palate  and 
uvula,  which  completely  shuts  off  the  nasopharynx,  while 
at  the  same  time  the  so-called  Passavant's  fold  or  emi- 
nence, on  the  posterior  pharyngeal  wall,  is  forced  into 
intimate  contact  with  the  soft  palate  by  contraction  of  the 
superior  constrictor  of  the  pharynx.  The  lateral  muscles 
of  the  pharynx,  the  palatoglossus  and  palatopharvngeus, 
at  the  same  time  force  the  bolus  into  the  median  line  and 
act  as  lateral  "  points  d'appui  "  for  the  contraction  of  the 
soft  palate.  From  this  point  to  the  esophagus  the  bolus 
is  propelled  exclusively  by  the  momentum  it  has  acquired 
and  which  suffices  to  hurl  it  down  bodily. 

The  act  of  deglutition,  both  in  its  origin  and  in  all  its 
subsequent  automatic  phases,  is  under  the  control  of  a 
deglutition  center  on  the  floor  of  the  fourth  ventricle.  This 
center  may  be  irritated  reflexly  through  the  superior  and 
inferior  laryngeal  nerves. 

The  great  importance  of  the  soft  palate  for  respiration 
and  speech  is  well  known.  During  ordinary  nasal  respi- 
ration it  is  relaxed  and  rests  loosely  on  the  base  of  the 
tongue.  During  oral  respiration  it  is  drawn  upward  and 
shuts  off  the  nasopharynx.  If,  owing  to  paralysis  or  im- 
perfect reflex  innervation,  as  during  sleep,  the  soft  palate 
fails  to  contract  when  the  mouth  is  open,  its  lower  edge 
is  thrown  into  coarse  vibrations  by  the  current  of  air  and 
the  individual  snores. 

The  soft  palate  likewise  plays  an  important  part  in  the 
production  of  speech.  Except  during  the  formation  of  the 
nasal  sounds  "  m  "  and  "  n,"  it  shuts  off  the  nasopharynx 


ANATOMY  AND  PHYSIOLOGY.  7 

fnMii  tlie  mouth,  its  anterior  horizontal  portion  being 
utilized  chiefly  for  this  purpose.  If  this  closure  fails  to 
be  effected,  part  of  the  air  escapes  through  the  nose,  and 
nasopalatine  dyslalia  or  rhinolalia  aperta  results.  The 
causes  of  this  condition  therefore  are  :  congenital  or  ac- 
quired defects,  either  of  the  soft  or  of  the  hard  palate ; 
insufficient  closure  of  the  nasopharynx,  due  to  paralysis 
or  to  shortness — that  is,  insufficiency  of  the  soft  palate,  or, 
in  some  cases,  merely  to  habit  and  functional  insufficiency 
following  paralyses  in  childhood. 

The  pharynx  also  contributes  its  share  to  speech-pro- 
duction, though  it  is  rather  a  negative  one — that  is  to 
say,  it  comes  into  play  in  the  presence  of  pathologic 
changes.  Gi'eat  enlargement  of  the  tonsils  interferes  with 
the  free  action  of  the  soft  palate  and  posterior  portion  of 
the  tongue  in  exactly  the  same  way  as  a  large  bolus  in 
the  mouth — the  individual  speaks  as  if  he  had  his  mouth 
full.  The  vibration  of  the  pharynx  lends  to  speech  its 
sonorous  quality.  If  there  is  marked  obstruction  or 
hyperplasia  of  the  tonsil,  speech  becomes  "dead,"  the 
sound  is  dull,  and,  owing  to  the  impossibility  of  the  air 
escaping  into  the  nose,  the  nasal  sounds  "  n  "  and  "  m," 
during  the  production  of  which  the  soft  palate  does  not 
shut  off  the  nasopharynx  above,  are  imperfectly  pro- 
nounced, the  sound  "  b  "  being  made  instead  of  "  m"  or 
"  n."     This  is  called  "  rhinolalia  clausa  posterior." 

The  framework  of  the  nose  rests  on  the  hard  palate, 
the  maxilla,  and  the  premaxillary  and  palatine  bones, 
which  give  support  along  the  median  line  to  the  vomer 
and  vertical  plate  of  the  ethmoid  bone.  The  lateral 
boundaries  are  formed  in  front  by  the  outer  portions  of 
the  maxilla,  in  the  middle  by  the  os  planum  of  the  ethmoid 
bone,  and  behind  by  the  pterygopalatine  process  of  the 
frontal  bone,  which  is  intercalated  between  the  nasal  proc- 
esses of  the  maxillae  ;  the  upper  boundary  by  the  frontal 
bone  proper,  the  lamina  cribrosa  of  the  ethmoid  bone, 
and  the  sphenoid.  The  external  nose,  in  addition,  pos- 
sesses a  central  support  in  the  quadrangular  cartilage  of 


8  PRELIMINARY  REMARKS  ON 

the  septum.  The  junction  of  this  cartihige  with  the  pre- 
maxillary  bone,  which  projects  into  the  Hoor  of  the  nose 
and  forms  a  vertical  ridge,  is  indicated  in  the  living  sub- 
ject by  the  crista  septi.  The  many  variations  of  this 
cartilagino-osseous  junction,  especially  in  a  lateral  direc- 
tion, are  often  erroneously  regarded  as  outgrowths  of  the 
septum  (Fig.  1,  c  s). 

The  upper  portion  of  the  septal  cartilage  is  bent  over 
laterally  in  the  shape  of  wings  that  form  the  alee  nasi, 
which  are  chiefly  supported  by  the  cartilaginous  ring  situ- 
ated lower  down.  The  latter  is 
formed  by  the  union  of  the  two 
septal  cartilages,  and,  in  addition, 
contains  the  greater  and  smaller 
alar  cartilages,  besides  a  few  in- 
terposed sesamoid  cartilages  that 
are  not  constantly  present.  The 
lowest  portion  of  the  septum, 
which  is  movable  and  connects 
the  tip  of  the  nose  with  the  up- 
FiG.i.-Anteriorviewofthe  per  lip,  forms  part  of  the  median 
L'^otatd  fer'toThJ  rS  :t  ^'^S^^  ^^  ^hc  large  alar  cartilages, 
seijtum ;  eg,  crista  septi ;  u,  in-     the  lateral  portion  of  which  ac- 

fenor  turbinate.  .  ^.    ■,    .  „ 

quires  a  special  importance  irom 
the  fact  that  it  lends  to  the  lowest  segment  of  the  alse  nasi 
the  necessary  stiffness  to  enable  them  to  resist  the  pressure 
of  the  inspiratory  air-current.  If  this  portion  of  the  aloe 
is  too  soft,  owing  to  prolonged  mouth-breathing  or  atrophy 
due  to  disuse,  or  if  the  dilator  muscles  contained  in  its 
substance  are  insufficient,  serious  impediment  to  respira- 
tion may  result  from  collapse  of  the  alae,  and  can  be  ob- 
viated only  by  wearing  some  supporting  apparatus.  The 
antero-inferior  corner  of  the  bony  septum  contains  on  one 
side  the  orifice  of  the  nasopalatine  canal,  which  'empties 
behind  the  first  incisors.  In  the  living  subject  this  canal, 
which  in  the  embryo  is  lined  with  epithelium,  is  oblit- 
erated, and  is  represented,  on  the  palate,  by  the  palatal 
papilla,  and,  in  the  nose,  by  the  nasopalatine  recess.     A 


ANATOMY  AND  PHYSIOLOGY.  9 

similar  rudimentary  epithelial  appendage  of  this  canal  is 
found  on  the  lowest  portion  of  the  septum  in  the  shape 
of  the  so-called  Jacobson's  organ,  which  is  found  fully 
developed  only  in  embryos  and  in  various  species  of  mam- 
mals, in  whom  it  subserves  the  function  of  smell. 

The  bony  and  cartilaginous  structure  just  described 
contains  the  two  nasal  cavities.  Within  these  are  found 
the  labyrinth  of  the  ethmoid  bone,  and  the  two  lateral 
masses  forming  the  superior  and  middle  turbinates,  and 
tlie  processes  of  the  superior  maxillae  that  form  the  in- 
ferior turbinates.  The  cavity  of  the  nose  is  surrounded 
on  all  sides  by  a  collection  of  small  pneumatic  spaces,  the 
accessory  sinuses,  consisting  of  three  large  pairs :  the 
maxillary  sinus  or  antrum  of  Highmore,  the  frontal,  and 
the  sphenoid  sinuses ;  and  the  labyrinth  of  the  ethmoid, 
which  is  made  up  of  a  number  of  pneumatic  cells.  The 
larger  cavities  may  also  be  converted  into  a  system  of 
cells  by  the  presence  of  projecting  bony  or  membranous 
septa.  In  the  accompanying  illustration  (Fig.  2)  these 
sinuses  are  shown  in  sagittal  section,  parallel  with  and  a 
little  to  the  left  of  the  septum,  the  turbinates  having  been 
removed. 

The  anterior  insertion  of  the  inferior  turbinate  (c  i) 
conceals  a  deep  recess  (?'  m  i)  which  contains  the  orifice 
of  the  lacrimal  duct ;  another  somewhat  shallower  and 
more  linear  depression,  known  as  the  recessus  meatus 
medii,  is  present  in  rudimentary  form  below  the  anterior 
rest  of  the  middle  turbinate  (c  m),  near  the  frontal  sinus 
(F).  From  the  lower  orifice  of  the  frontal  sinus  a  funnel- 
shaped  cavity,  known  as  the  "  infundibulum,"  extends 
between  the  most  anterior  cells  (E  a)  of  the  os  planum  of 
the  ethmoid  and  the  middle  turbinate  into  the  middle 
meatus  toward  the  large  opening  of  the  antrum,  designated 
the  ostmm  maxillare.  The  latter  communicates  with  the 
openings  of  the  anterior  and  middle  ethmoid  cells  (E  a), 
the  most  prominent  of  which  has  received  the  unneces- 
sary designatiou  of  ethmoid  bulla,  while  the  group  of 
posterior  cells  {F p)  open  on  the  mesial  side  of  the  middle 


10 


PRELIMINARY  REMARKS  ON 


turbinate,  about  the  middle  of  the  superior  meatus,  at  a 
point  kno'vn  as  tiie  splieno-ethmoid  recess  (>•  .s  e). 


Fig.  2.— Sagittal  section  paraUel  with  and  a  little  to  the  left  of  the  septum. 
The  turbinates  and  the  inner  walls  of  most  of  the  ethmoid  cells  (colored  red) 
have  been  almost  completely  removed.  One  of  the  turbinates  is  seen  through 
the  intact  wall.  A  portion  of  the  os  planum  has  also  been  removed,  so  that  a 
wide  view  of  the  antrum  is  afforded.  The  probe  has  been  introduced  into  the 
infundibulum  by  way  of  the  frontal  sinus.  The  sphenoid  sinus  (S)  is  colored 
blue. 

The  opening  of  the  antrum  (Fig.  3)  forms  a  wide  cleft 
running  into  a  jioint  in  front  and  above.  In  the  living 
subject  it  is  considerably  smaller  on  account  of  its  mem- 


ANATOMY  AND  PHYSIOLOGY.  11 

branous  lining.  It  is  bounded  below  by  the  inferior  tur- 
binate, above  by  the  lowest  portion  of  the  os  planum  of 
the  ethmoid  bone  and  a  portion  of  the  labyrinth.  The 
lining  membrane  sometimes  contains  accessory  orifices  in 
addition  to  the  large  main  opening  of  the  antrum.  The 
inner  wall  of  the  antrum  forms  the  outer  wall  of  the  infe- 
rior nasal  meatus ;  the  upper  wall  corresponds  with  the 
inferior  surface  of  the  orbit,  and  the  anterior  wall  with 
the  malar  surface  of  the  maxilla.  The  floor  terminates 
in  a  moderately  wide  sagittal  furrow,  known  as  the  alve- 
olar recess,  and,  when  the  cavity  is  very  large,  extends 
over  all  the  molar  and  bicuspid  teeth,  giving  rise  to  the 
formation  of  nimierous  ""  haustra,"  or  circular  depressions 
bounded  .by  projecting  ridges  of  bone.  Similar  depres- 
sions are  found  in  the  other  accessory  sinuses,  especially 
in  the  frontal  sinus. 

When  the  bony  or  membranous  projections  are  unusually 
well  developed,  they  may  form  complete  or  partial  cells. 
The  accessory  cavities  vary  widely  in  size ;  the  antrum 
may  be  the  size  of  a  walnut,  or  may  be  reduced  to  a  mere 
shallow  pit,  or  may  even  be  entirely  replaced  by  spongy 
or  solid  bone.  Abnormal  reduction  in  size,  or  absolute 
deficiency  of  the  frontal  and  sphenoid  sinuses,  is  not 
noticeable  on  the  exterior  of  the  skull.  Underdevelop- 
ment or  absence  of  the  ethmoid  labyrinth  reveals  itself 
by  an  abnormal  width  of  the  nasal  meatus ;  if  the  antrum 
is  small  or  obliterated,  it  leads  to  flattening  of  the  face, 
production  of  a  high  palate,  and  lateral  enlargement  of 
the  inferior  nasal  meatus. 

Hypoplasia  of  the  turbinates  involving  both  the  bone 
and  the  soft  parts  is  observed  with  especial  frequency  in 
brachycephalic  individuals  in  whom  the  nasal  cavities  are 
usually  enlarged.  The  extraordinary  increase  in  the  size 
of  the  nasal  meati  predisposes  to  the  development  of 
"  ozena,"  a  condition  in  which  abnormal  secretions  origi- 
nating in  some  portions  of  the  nose  stagnate  and  become 
inspissated  or  undergo  decomposition,  because  the  re- 
tarded air-current  in  the  dilated  meati  is  unable  to  expel 


12 


PRELIMINARY  REMARKS  ON 


them.  The  presence  of  these  decomposintr  masses  exerts 
an  injurious  influence  on  the  epithelium  and  on  the  already 
meager  submucosa.  Accordingly,  it  is  extremely  difficult 
in  all  these  cases  to  distinguish  between  congenital  aplasia 
and  acquired  atrophy. 

The  principal  develo])ment  of  the  system  of  accessory 


Fig.  3.— Antrum  ot  Highmore  laid  open  by  means  of  an  exterior  sagittal 
section.  The  ostium  maxillare  is  seen  on  the  floor  of  the  sinus.  Above  the 
sinus,  part  of  the  os  planum  has  been  torn  away  from  the  orbit,  affording  a 
view  of  the  anterior  ethmoid  cells. 


sinuses  begins  after  the  completion  of  first  dentition,  as 
the  odontoblasts  at  first  practically  fill  the  antrum  as  far 
as  the  orbit.  The  other  cavities  also  do  not  acquire  their 
true  shape  before  the  third  or  the  fourth  year  of  life. 

The  lining  membrane  of  the   nose  in  the  anterior  por- 
tion,  known  as  the   vestibule,  is  composed  of  stratified 


ANATOMY  AND  PHYSIOLOGY.  13 

squamous  epithelium  very  similar  to  the  adjoining  epi- 
dermis, and  contains  sebaceous  glands,  hair-follicles,  and 
hairs,  or  vibrissae.  The  boundary  between  the  vestibule 
and  the  internal  nose  proper,  as  may  be  remarked  inci- 
dentallv,  corresponds  to  the  junction  of  the  cartilaginous 
external  nose  with  the  bony  portion ;  and,  on  the  floor  of 
the  nose  and  septum,  to  a  line  connecting  the  nasal  spine 
of  the  maxilla  with  the  tip  of  the  nasal  bone ;  this  line 
also  includes  the  anterior  extremity  of  the  inferior  tur- 
binate. In  this  region  there  is  a  transitional  zone  of 
roundish  epithelium,  but  still  destitute  of  glands.  The 
true  mucous  membrane  is  said  to  begin  at  the  point  where 
glands  first  make  their  appearance.  That  portion  of  the 
mucous  membrane  which  contains  the  olfactory  cells  is 
known  as  the  olfactory  region ;  the  remaining  portion  is 
called  the  respiratory  region.  For  practical  purposes  it 
is  well  to  retain  these  inadequate  and,  at  least  so  far  as 
the  latter  is  concerned,  incorrect  designations. 

The  investment  of  the  mucous  membrane  proper  con- 
sists of  several  layers  of  cylindric  epithelium,  the  upper- 
most cells  of  which  are  provided  with  cilia  that  set  up  an 
outward  current.  The  stroma  of  the  mucosa  is  rather 
thin,  and  its  subepithelial  basal  layer  is  traversed  by  minute 
lymph-clefts  that  appear  to  communicate  directly  with 
the  lymphatic  plexus.  These  lymph-clefts  convey  to  the 
surface  a  watery  lymph  containing  very  little  albumin, 
which  provides  the  cilia  with  the  fluid  necessary  for  their 
vibratory  function  as  well  as  the  respiratory  air  with  its 
necessary  amount  of  moisture.  The  direct  communica- 
tion between  the  olfactory  region  and  the  basal  lymph- 
channels  of  the  dura  mater  has  been  demonstrated  beyond 
a  doubt. 

The  thickness  of  the  mucous  membrane  is  increased 
wherever  the  characteristic  nasal  erectile  tissue  is  im- 
bedded in  the  stroma.  The  erectile  tissue  is  interposed 
in  the  continuity  of  the  venous  plexus,  which  receives  the 
finest  venous  capillaries  of  the  surface  and  empties  into 
the  veins  of  the  submucosa.    The  erectile  tissue,  although, 


14  PRELIMINARY  REMARKS  ON 

strictly  speaking,  a  venous  structure,  contains  in  the  walls 
of  its  individual  vessels  a  more  robust  muscular  layer  than 
is  found  in  arteries,  the  muscle- tissue  forming  large,  beam- 
like projections  into  the  lumen.  Erectile  tissue  is  found 
on  the  lower  turbinate,  at  the  edge  and  posterior  extremity 
of  the  middle  turbinate,  at  the  posterior  extremity  of  the 
upper  turbinate,  and  tinally  on  a  prominence  of  the  septum 
opposite  tiie  anterior  extremity  of  the  middle  turbinate, 
known  as  the  tuberculum  septi.  Under  ordinary  circum- 
stances the  erectile  tissue  is  contracted.  When  filled  with 
blood,  however,  it  represents  a  thick  red  cushion  which 
completely  fills  the  nasal  cavity,  even  when  it  is  normal 
in  width,  making  it  absolutely  impermeable  to  air.  Sev- 
eral degrees  of  obstruction  are,  of  course,  observed. 

The  mucous  membrane  is  thinnest  in  the  accessory 
sinuses,  where  the  stroma  is  represented  by  the  periosteum 
of  the  bone.  The  membrane  lining  the  sinuses  contains 
a  few  blood-vessels,  and  only  at  long  intervals  an  occa- 
sional gland,  so  that  it  a])pears  as  a  delicate  gray  film. 
The  glands  in  this  region  and  in  the  respiratory  portion 
of  the  nose  generally  are  mostly  of  the  acinous  variety. 
Their  secretion  consists  chiefly  of  mucus,  although  some 
of  them  produce  serum.  The  glands  are  most  abundant 
at  the  tuberculum  septi. 

The  glands  of  the  olfactory  region,  on  the  other  hand, 
are  tubular  albuminous  glands  j^roducing  a  Avatery  secre- 
tion. This  region  includes  an  area  of  about  2  to  3  c.c. 
on  the  roof  of  the  nose,  the  superior  turbinate,  and  the 
septum  on  each  side,  occupying  approximately  the  center 
of  the  sagittal  diameter  of  the  nose,  and  is  characterized 
by  a  yellowish-brown  color,  in  contrast  to  the  remaining 
mucous  membrane,  which  is  red.  The  region  is  inter- 
spersed with  small  islands  of  ordinary  mucous  mendirane 
covered  with  ciliated  epithelium.  The  olfactory  mem- 
brane proper  rests  directly  on  the  lymphadenoid  base, 
consisting  of  accumulations  of  round-cells  forming  folli- 
cles, and  covered  by  non-ciliated  sustentacidar  epithelium 
interspersed  with  a  few  true  olfactory  cells.     The  latter 


ANATOMY  AND  PHYSIOLOGY.  15 

are  epithelial  cells  provided  with  delicate  olfactory  hairs 
at  their  free  extremity,  and  Avith  their  basal  extremity 
merging  directly,  through  the  medium  of  delicate  fibrils, 
with  the  terminal  ramifications  of  the  olfactory  nerve. 
The  subepithelial  layer  of  lymph-cells,  like  the  basement 
membrane,  is  traversed  by  minute  basal  canaliculi  which 
have  been  shown  to  be  in  communication  with  the  sub- 
arachnoid and  subdural  lymph-spaces. 

Scattered  masses  of  lymphoid  tissue  are  also  distributed 
over  the  entire  respiratory  portion,  sometimes  collected 
to  form  follicles. 

The  blood-supply  of  the  nose  is  as  follows  :  the  facial 
artery  nourishes  the  external  nose,  the  septum,  and  the 
internal  mucous  membrane  ;  the  frontal  and  ophthalmic 
arteries  are  distributed  to  the  external  nose ;  the  ethmoid 
artery  supplies  the  anterior  portion  of  the  septum ;  the 
sphenopalatine  artery  goes  to  the  posterior  portion  of  the 
septum  ;  remaining  branches  of  the  internal  maxillary 
artery  are  variously  distributed.  The  veins  of  the  external 
nose  empty  into  the  angular  vein ;  those  of  the  internal 
into  the  sphenopalatine  and  ethmoid  veins :  and  in  addi- 
tion communicate  with  the  cavernous  plexus  and  the 
longitudinal  sinus. 

The  vascular  arrangement  in  the  so-called  "  locus  Kies- 
selbachii,"  an  area  situated  at  the  antero-inferior  angle 
of  the  septum,  is  peculiar :  under  a  delicate  covering  of 
squamous  epithelium  a  number  of  narrow  and  high  papillae 
are  found,  containing  large  veins  and  a  dense  capillary 
network,  an  anatomic  condition  which  favors  the  occur- 
rence of  stubborn  hemorrhage  at  this  point,  which  by  its 
location  is  already  exposed  to  injury,  such  as  scratching 
with  the  finger  or  the  removal  of  crusts. 

In  addition  to  the  branches  of  the  olfactory  nerve 
within  the  olfactory  membrane  the  innervation  of  the  nose 
is  effected  by  branches  of  the  first  and  second  divisions 
of  the  trigeminal  nerve.  These  nerves  contribute  to  the 
perception  of  smell  by  conveying  the  stimuli  produced  by 
so-called  sharp  odors,  such  as  ammonia.     Irritation  of 


16  PRELIMINARY  REMARKS  ON 

the  sphenopalatine  ganglion  is  followed  by  engorgement 
of  the  erectile  tissue  in  the  lower  turbinate.  The  motor 
fibers  for  the  few  muscular  bundles  of  the  external  nose 
run  in  the  buccal  branches  of  the  lacial  nerve.  The  main 
functions  of  the  nose  are  the  perception  of  odors  and 
preparatory  warming,  cleansing,  and  moistening  of  the  in- 
spired air.  For  this  purpose  the  inspired  air  must  come 
into  contact  with  as  great  an  extent  of  the  olfactory  mem- 
brane and  the  moist  warm  surfaces  of  the  mucous  mem- 
brane covering  the  turbinate  as  possible.  Accordingly 
the  inspiratory  air-current,  instead  of  hugging  the  floor 
of  the  nose,  follows  an  elliptic  course  from  the  vestibule 
to  the  middle  and  superior  turbinates,  and  from  this  point 
along  the  roof  of  the  nose  and  beneath  the  sphenoid  sinus 
to  the  posterior  extremity  of  the  inferior  turbinate. 
During  this  course  it  does  not  remain  in  the  same  vertical 
plane,  but  deviates  toward  the  median  line  soon  after  it 
leaves  the  anterior  extremity  of  the  middle  turbinate. 
The  expiratory  air-current  follows  the  same  course.  It 
is  obvious,  therefore,  that  respiration  is  impeded  only 
when  there  is  an  alteration  of  the  lumen  along  the  track 
described,  and  that  even  an  extensive  obstruction  in  other 
portions  of  the  nose,  as,  for  instance,  on  the  floor  of  the 
middle  meatus,  may  produce  no  symptoms,  while,  on  the 
other  hand,  even  marked  deviations  may  be  present  with- 
out interfering  with  respiration  if  their  position  is  such  as 
to  permit  the  respiratory  current  to  avoid  them  and  pass 
into  some  other  cavity. 

The  mechanism  of  nasal  respiration  is  as  follows  :  The 
column  of  air  which  during  apnea  is  under  the  same 
pressure  as  that  of  the  atmosphere  follows  the  inspiratory 
negative  pressure  which  is  propagated  from  the  trachea 
upward,  and  thus  makes  room  for  the  external  air  to  rush 
in  and  take  its  place.  The  change  in  air-pressure  like- 
wise affects  the  air  within  the  accessory  sinuses,  and  in 
these,  as  well  as  in  the  nose,  a  positive  change  of  pressure 
is  observed  during  expiration.  It  is  at  this  moment  that 
the  pneumatic  spaces   assume  a  physiologic  importance. 


ANATOMY  AND  PHYSIOLOGY.  17 

Most  of  them  empty  into  the  infundihulum ;  a  few  into 
the  upper  nasal  meatus.  As  during  inspiration,  the  air 
is  drawn  out  of  the  sinuses  and  a  negative  pressure  is 
produced,  tlie  outer  air  immediately  makes  for  these  cav- 
ities instead  of  for  the  inferior  meatus,  and  tluis  passes 
over  and  comes  in  contact  with  the  olfactory  region,  to 
which  it  conveys  olfactory  impressions.  This  explains 
why  odors  are  perceived  at  the  very  beginning  of  inspi- 
ration, and  why  the  presence  of  objects  within  the  nose 
is  detected  by  the  sense  of  smell  only  when  the  object 
is  lodged  in  the  infundibulum  or  its  accessory  spaces. 
Hence  the  odor  from  offensive  crusts  or  sequestra  on  the 
floor  of  the  nose  is  not  perceived  by  the  individual,  and, 
on  the  other  hand,  offensive  suppurations  within  the  an- 
trum, for  instance,  betray  themselves  by  subjective  cacos- 
mia,  although  the  observer  cannot  detect  the  odor  in  the 
expired  air.  The  mechanism  also  explains  the  occurrence 
of  subjective  anosmia  in  stenoses,  even  in  the  presence  of 
abnormal  dilatation  of  the  inferior  nasal  meatus ;  in  both, 
cases  the  inspired  air  fails  to  reach  the  olfactory  region, 
and  although  the  olfactory  membrane  is  intact,  the  smell 
is  abolished.  Bizarre  variations  between  anosmia  and 
hyperosmia  also  certainly  occur  during  local  treatment, 
explained  by  the  fact  that  olfactory  cells  which  usually 
lie  fallow  are  irritated  by  a  sudden  inrush  of  stimuli, 
and  the  patient  reacts  to  the  novel  smell  with  headache. 
The  importance  of  nasal  respiration  for  the  well-being 
of  the  entire  organism  is  not  confined  to  preparatory 
warming  and  moistening  of  the  inspired  air.  There  is 
no  doubt  that  the  amount  of  air  that  can  be  aspirated 
through  the  mouth  is  quantitatively  inadequate  for  the 
needs  of  the  organism.  Whether  this  is  owing  to  the 
retardation  of  tlie  air-current  produced  by  its  striking 
the  hard  palate  and  posterior  wall  of  the  pharynx,  or 
whether  air  that  has  not  been  previously  warmed  acts 
as  an  expiratory  reflex  stimulus  before  inspiration,  has 
been  completed,  it  is  certain,  on  experimental  grounds, 
that  exclusive  mouth-breathing  of  acute  origin  rapidly 


18      REMARKS  ON  ANATOMY  AM)  PHYSIOLOGY. 

leads  to  dyspnea,  while  habitual  mouth-breathers,  either 
because  their  sensibilities  liave  been  blunted  or  because 
they  have  become  habituated  to  the  abnormal  condition, 
do  not  complain  of  shortness  of  breath,  although  the  tis- 
sues of  the  body  distinctly  show  the  effects  of  insufficient 
oxygenation. 

Finally,  nasal  respiration  exerts  an  important  influence 
on  the  circulation  at  the  base  of  the  skull ;  when  the 
nasal  passages  are  unobstructed,  every  ins[)iration  empties 
the  ethmoid  veins,  and  through  them  the  longitudinal 
sinus  and  the  cavernous  plexus.  If  the  nose  becomes 
obstructed  and  this  mechanism  is  interfered  with,  venous 
hyjieremia  of  the  meninges  is  apt  to  occur,  and  then 
favors  the  development  of  those  cerebral  phenomena 
with  which  the  reader  will  be  made  acquainted  more 
intimately  in  the  section  on  Mouth-breathing. 


GENERAL   REMARKS   ON    PATHOLOGY. 


The  causes  of  most  diseases  that  form  the  subject  of 
this  discussion,  otlier  than  the  general  infectious  diseases, 
are  to  be  sought  in  irrational  ways  of  living ;  coddling, 
want  of  cleanliness,  excessive  exertion,  and  imprudence 
generally,  both  in  health  and  in  disease. 

The  infectious  diseases,  especially  the  diseases  of  chil- 
dren, produce  and  leave  in  their  wake  a  great  number  of 
more  or  less  important  sequelae  :  in  the  pharyngeal  space, 
inflammations  and  hyperplasia  of  the  lymphatic  ring  ;  in 
the  nose,  hyperemia,  hyperplasia,  and,  above  all,  localized 
catarrh  or  suppuration.  The  acute  inflammatory  diseases 
are  often  followed  by  grave  consequences,  and  chronic 
secretory  anomalies  due  especially  to  the  failure  of  apply- 
ing rational  treatment  in  time.  In  the  early  stage, 
during  the  fever  and  during  convalescence  from  the  acute 
exantiiemata  and  other  infectious  diseases,  especially 
typlioid  fever,  it  is  of  the  greatest  importance  to  be  on 
the  lookout  for  nasopharyngeal   complications. 

In  both  a  state  of  nature  and  in  civilized  life  the 
demands  on  the  mucous  membrane  are  considerable,  and 
the  individual  should  be  taught  in  early  childhood  not 
to  avoid  these  demands,  but  to  learn  how  to  enable  his 
tissues  to  satisfy  them.  The  muscles  of  the  blood-vessels 
must  learn  gymnastics — i.  e.,  they  must  be  taught  to  meet 
sudden  effects  of  heat  and  cold  by  a  corresponding  con- 
traction or  dilatation.  This  object  is  attained  by  sleeping 
under  a  light  covering  which  permits  evaporation  to  take 
place,  and  not  so  warm  as  to  cause  the  sleeper  to  uncover 
himself  partly  during  the  night.     If  possible,  the  win- 

19 


20  GENERAL   REMARKS  GN  PATHOLOGY. 

dows  should  be  opened,  without,  however,  the  production 
of  a  draught.  In  the  summer-time  one  siiould  bathe  in 
cold  water,  and  every  warm  batli  should  be  followed  by 
a  cold  affusion.  Children  should  be  made  to  indulge  in 
gymnastics,  swimming,  and  running.  The  practice  of 
protecting  the  throat  is  especially  objectionable,  and  will 
revenge  itself  the  first  time  that  the  individual  is  forced 
by  circumstances  to  expose  himself.  Among  injurious 
influences  must  be  included  our  irrational  way  of  dressing 
in  the  winter-time.  Our  clothes  are  made  of  too  heavy 
material,  which  makes  the  wearer  perspire  in  the  warmth 
of  the  room,  whereas  a  warm  upper  garment  over  a  suit 
of  lighter  material  would  be  much  mon;  appropriate. 
Another  bad  practice  consists  in  wearing  woolen  under- 
wear, which  is  needed  only  by  those  who  have  to  work 
themselves  into  a  perspiration,  and  must  therefore  avoid 
too  sudden  cooling  when  they  stop  working.  In  city 
people  the  woolen  underclothing  only  produces  a  dis- 
agreeable smell  of  perspiration  and  excessive  sensitiveness 
of  the  skin.  Among  the  injurious  influences  are  included 
also  steam-baths,  which  have  become  so  popular,  and  the 
too  frequent  indulgence  in  which  robs  the  skin  of  fat, 
tlius  reducing  its  powers  of  resistance. 

Cleanliness  is  a  point  of  the  greatest  importance. 
Water  is  the  most  effective  stimulus  for  the  cutaneous 
vessels,  and  in  addition  removes  decomposition-products 
of  the  secretion  that  irritate  the  skin,  and  an  untold 
number  of  dangerous  carriers  of  infection,  A  sense  of 
cleanliness  keeps  one  from  first  dusting  his  boots  with  a 
handkerchief  and  then  blowing  his  nose  with  it ;  from 
patting  a  dog  and  in  the  next  instant  carrying  the  hand 
to  the  mouth ;  from  shaking  hands  with  a  patient  and 
immediately  afterward  picking  particles  of  dirt  out  of 
the  nose  or  taking  a  piece  of  bread  ;  from  kissing  our 
neighbor's  child  an<l  wondering  at  the  disagreeable  odor, 
which,  as  a  matter  of  fact,  has  its  origin  in  our  own  pre- 
cious mouth  with  its  few  remaining  decayed  stumps,  that 
do  not,  it  is  true,  trouble  the  owner  because,  forsooth. 


CAUSES.  21 

they  do  not  hurt.  A  sense  of  cleanliness  protects  us 
against  a  number  of  infections  because  it  teaches  us  not 
to  poke  our  noses  and  our  fingers  into  all  sorts  of  things, 
and  not  to  eat  or  drink  an}thing  that  we  have  good 
reason  to  suspect  is  not  what  it  should  be.  Fiually,  it 
teaches  us  to  change  our  clothes  often  enough  to  keep  the 
skiu  in  the  proper  state  of  irritability  aud  evaporation. 

On  the  other  hand,  one  should  not  expect  too  much 
from  the  natural  protections  and  the  power  of  reaction 
of  the  organism.  If  a  man  with  irritable  mucous  mem- 
brane smokes  all  day,  he  need  not  wonder  that  he  has 
to  spit  all  day.  Daily  or  even  fairly  frequent  abuse  of 
alcohol  roljs  the  general  powers  of  resistance,  acts  as  a 
direct  stimulant  to  the  oral  and  })harvngeal  mucous  mem- 
branes, and  brings  on  oral  and  venous  hyperemia,  with 
the  well-known  result  of  morning  vomiting,  which  is 
brought  on  by  some  condition  in  the  throat,  and  not,  as 
is  usually  su])posed,  in  the  stomach.  Feverish  activity 
without  a  proper  amount  of  relaxation,  combined  with 
mental  excitement,  such  as  the  greed  for  professional 
reputation  or  the  striving  for  social  prominence,  pre])ares 
the  soil  for  neurasthenia,  after  which  the  slightest  local 
causes  may  start  up  the  symptom-complex  of  the  reflex 
neuroses,  of  paresthesia,  and  of  hypochondriasis.  The 
question  of  hardening  must  be  carefully  considered,  and 
the  line  drawn  at  the  boundary  where  an  individual 
whose  powers  of  reaction  have  already  been  weakened 
by  disease,  worry,  or  other  similar  causes,  responds  to 
fatigue  by  relaxation  of  his  blood-vessels  instead  of  by 
renewed  tension,  and  so  becomes  ill,  either  directly  or 
because  his  resistance  to  infection  has  become  diminished. 
Anemic  women  and  children,  syphilitic  individuals,  or 
those  afflicted  with  or  predisposed  to  tuberculosis  ;  patients 
recovering  from  acute  infectious  disease  ;  or  those  who, 
for  some  other  reason,  have  been  bed-ridden  or  confined 
to  their  rooms  for  some  time  ;  and,  lastly,  the  subjects  of 
arteriosclerosis  or  venous  hyperemia — need  to  be  cautioned 
against  the   effects  of  heat  and  cold  rather  than  encour- 


22  GENERAL  REMARKS  ON  PATHOLOGY. 

aged  to  expose  themselves  for  the  purpose  of  taking 
exercise. 

Both  the  nose  and  the  mouth  in  civilized  man  require 
a  certain  amount  of  care.  Failure  to  cleanse  the  teeth 
regularly,  as  well  as  a  habitual  incorrect  method  in 
brushing  the  teeth,  will  invariably  lead  to  caries  of  the 
teeth,  and  will  also  predispose  to  oral  and  pharyngeal 
catarrh,  as  well  as  to  disease  of  the  nose,  which  so  fre- 
quently accompanies  caries  of  the  teeth.  The  usual  prac- 
tice of  cleansing  the  teeth  by  brushing  them  in  the  hori- 
zontal direction  is  especially  to  be  condemned  because 
the  tendency  of  this  method  is  to  force  the  foreign  matter 
into  the  interstices  of  the  teeth  instead  of  removing  it. 
The  teeth,  especially  if  they  have  begun  to  decay,  should 
be  cleansed  after  eating  and  before  retiring  at  night, 
when  it  is  much  more  important  than  on  getting  up  in 
the  morning.  After  taking  alcohol  or  smoking  it  is  espe- 
cially important  to  rinse  the  mouth.  In  this  dusty  age 
of  ours,  even  the  healthiest  individuals  whose  mucous 
membranes  secrete  practically  nothing  need  to  blow  their 
noses, and  in  children,  whose  mucous  membranes  are  always 
irritable  and  more  or  less  prone  to  secrete,  it  is  absolutely 
indispensable.  As  a  rule,  the  child  is  taught  to  do  this 
improperly  in  earliest  youth.  He  is  told  to  close  both 
nostrils  tightly  and  then  to  blow  with  all  his  might. 
There  is  no  better  way  to  force  secretions  and  pathogenic 
germs  from  the  tubes  into  the  middle  ear  and  accessory 
sinuses  of  the  nose,  and,  by  producing  an  excessive  expira- 
tory pressure,  to  increase  an  already  existing  hyperemia 
of  the  turbinates,  which  brings  about  permanent  catarrh, 
not  to  mention  the  fact  that,  of  course,  nothing,  or  at 
least  very  little  secretion,  is  removed.  The  rational  way 
to  blow  one's  nose  is  to  leave  one  side  completely  free, 
and  to  increase  the  velocity  of  the  air  by  pressing  the 
other  side  ;  this  should  be  practised  alternately  on  each 
nostril. 

A  good  many  people  have  an  abiding  faith  in  the  effi- 
cacy of  snuffing  up  cold  water  every  morning  to  cure 


SYMPTOMS.  23 

their  nasal  catarrh.  To  show  the  utter  fallacy  of  this 
simple  and  "  healthful "  practice,  it  is  only  necessary  to 
place  a  few  freshly  removed  cells  of  cylindric  epithelium 
on  the  microscope,  and  note  how  the  lively  vibration  of 
the  cilise  is  immediately  checked  by  the  addition  of 
nothing  more  powerful  than  a  little  cold  water,  which  is 
rank  poison  to  the  nasal  mucous  membrane.  Solutions 
intended  for  use  in  the  nose  should  have  a  temperature 
of  not  less  than  25°  C.  (77°  F.),  and  should  contain  about 
as  much  salt  as  the  blood — 0.6  per  cent. 

How  irrational  it  is  to  neglect  the  mucous  membranes 
of  the  upper  air-passages  in  disease,  especially  in  children  ! 
No  one  thinks  of  allowing  a  stuporous  patient  to  remain 
long  in  his  urine  or  feces — the  skin  would  show  the 
effects  soon  enough,  not  to  speak  of  our  own  subjective 
sense  of  smell ;  but  no  care  is  taken  to  remove  the 
excessive  secretion  in  the  mouth,  nose,  and  especially 
nasopharynx,  which  speedily  undergoes  decomposition,  as 
evidenced  by  the  odor  of  the  breath,  whereas  systematic 
cleansing  of  these  structures  would  undoubtedly  suffice 
to  prevent  the  development  of,  let  us  say,  otitis  in  measles 
and  scarlet  fever.  When  the  throat  is  inflamed,  it  is 
customary  to  use  ice-cold  gargles  to  allay  the  sense  of 
thirst  produced  by  the  dryness  of  the  mucous  membrane, 
and  this  pernicious  practice  tends  merely  to  produce  an 
increased  hyperemia  when  reaction  takes  place,  whereas 
warm  or  even  hot  gargles  would  relieve  the  venous 
engorgement. 

Symptoms. — A  number  of  symptoms  are  common  to 
all  the  diseases  of  the  region  with  which  we  are  con- 
cerned. Any  acute  or  more  than  temporary  inflamma- 
tion produces  a  bad  taste  in  the  mouth,  which  is  not 
necessarilv  present  in  uncomplicated  gastric  affections, 
even  if  the  tongue  is  coated.  Another  symptom  that 
almost  regularly  accompanies  inflammations  of  the  oro- 
pharvnx  and  makes  its  appearance  at  the  very  outset  is 
the  well-known  fetor  of  the  breath,  the  quality  of  which 
will  enable  the  expert  at  once  to  distinguish  the  various 


24  GENERAL  REMARKS  ON  PATHOLOGY. 

kinds  of  inflammatory  conditions.  All  inflammatory 
conditions  of  the  mouth,  and  many  of  those  that  affect 
the  pharynx,  are  accompanied  by  profuse  salivation, 
which  may  be  the  most  troublesome  symptom  complained 
of  by  the  patient.  If  the  inflammation  lasts,  calcareous 
deposits  separate  from  the  secretion  and  adhere  to  the 
tissue  in  the  form  of  tartar.  The  alkaline  reaction  of  the 
saliva  favors  the  growth  of  saprophytic  colonies,  especially 
in  children.  Diseases  of  the  pharynx  are  usually  charac- 
terized by  a  sense  of  dryness  and  scratching  in  the  throat ; 
pain,  that  may  be  burning  or  stabbing  in  character,  and, 
if  intense,  may  radiate  to  the  ears ;  and,  finally,  by  dys- 
phagia. Hoarseness  always  points  to  some  disease  of  the 
larynx,  and  should  lead  the  physician  to  examine  that 
structure  as  well  as  the  pharynx.  Both  pain  and  abnormal 
sensations  in  the  throat  are  always  incorrectly  localized 
by  the  patient,  being  usually  referred  to  a  point  deeper 
than  their  origin.  If  the  physician  finds  an  irritative 
point  of  this  kind,  he  must  be  very  careful  to  avoid  letting 
the  patient  know,  either  by  allowing  him  to  watch  the 
introduction  of  the  probe  or  by  directly  telling  him  that 
the  irritation  is  situated  scmiewhere  else  and  usually  higher 
np  than  the  patient  thinks.  The  physician  is  more  apt 
to  lose  his  patient  than  the  patient  is  to  give  up  his  pre- 
formed conviction. 

A  prominent  symptom  in  nasal  disease  is  obstruction. 
Its  earliest  and  most  reliable  sign  is  a  feeling  of  dryness  in 
the  throat  on  waking  up.  In  minor  grades  of  respiratory 
obstruction  the  mouth  will  be  closed  reflexly  in  waking 
hours.  During  sleep,  however,  the  reflex  is  abolished, 
the  air  penetrates  to  the  throat  without  being  previously 
warmed  and  moistened,  producing  the  symptom  of  dry- 
ness, for  which  the  patient,  as  a  rule,  is  quite  unable  to 
account.  The  dryness  also  occurs  whenever  an  additional 
demand  is  made  on  the  respiration  during  rapid  walking, 
climbing  of  hills,  and  other  active  exercises.  Severer 
grades  of  obstruction  lead  to  permanent  mouth-breathing 
and  its  unpleasant  consequences.     The  loss  of  moisture 


SYMPTOMS.  25 

by  evaporation  in  the  pharyngeal  mucous  membrane  favors 
the  action  of  infectious  organisms,  which,  under  normal 
circumstances,  are  suspended  in  the  mucus,  and  thus  ren- 
dered innocuous  or  expelled.  But  little  attention  is  paid 
to  the  bad  effects  on  the  gums  and  teeth,  which  in  juve- 
nile mouth-breathers  especially  are  rarely  found  to  be 
intact,  because*  the  constant  liability  of  the  oral  mucus  to 
be  decomposed  by  the  innumerable  bacteria  must  be  com- 
bated for  the  protection  of  the  delicate  enamel  by  restoring 
normal  conditions  of  secretion.  That  this  is  true  is  shown 
by  tiie  ragged  edges  of  the  incisors  which  are  first  ex- 
posed. 

The  failure  on  tiie  part  of  the  raucous  membrane  to 
arrest  organic  and  inorganic  foreign  matters  in  the  inspired 
air  during  its  passage  and  to  supply  the  necessary  mois- 
ture is  not  a  matter  of  indifference,  just  as  the  changes  in 
the  direction  of  the  inspiratory  and  expiratory  air  are  not 
without  influence  on  the  upper  air-passages  and  the  lungs. 
Tiie  first  condition  favors  tiie  mechanical  production  of 
catarrh  in  the  larynx  and  bronchial  tree,  as  well  as  that 
chronic  irritative  condition  which  prepares  the  way  for 
the  growth  of  the  tubercle  bacillus,  the  direct  introduc- 
tion of  wiiich,  as  well  as  of  other  bacteria  in  large  num- 
bers, is  thereby  greatly  facilitated,  while  the  second  factor 
— /.  e.y  the  failure  to  moisten  the  inspiratory  air — is  fol- 
lowed by  a  number  of  injurious  results.  The  air,  instead 
of  being  conveyed  in  a  continuous  arching  stream  through 
the  nasopharynx  and  downward  in  a  line  almost  parallel 
with  the  posterior  pharyngeal  wall,  impinges  directly  on 
the  latter,  becomes  arrested  at  that  point,  and  then  re- 
quires to  reach  the  lower  air-passages  a  greater  inspiratory 
effort,  and.  similarly,  its  removal  from  the  lungs  requires 
increased  exploratory  pressure.  The  result  is  diminished 
ventilation  of  the  lung  and  its  sequelae :  anemia  from  in- 
sufficient oxygenation  of  the  blood  ;  diminished  powers 
of  resistance  against  infection ;  in  severe  grades  a  perma- 
nent increase  in  the  residual  air,  with  the  production  of 
pulmonary    distention, — emphysema  of  occult   origin, — 


26  GENERAL  REMARKS  ON  PATHOLOGY. 

which  is  still  further  increased  by  repeated  excessive  ex- 
piratory efforts  made  in  the  attempt  to  expel  the  increased 
masses  of  secretion  which  often  accompany  nasal  obstruc- 
tion, so  that  even  the  formation  of  a  hernia  may  in  some 
cases  be  attributed  to  these  faulty  conditions.  In  the  same 
way  deformities  of  the  thorax  (see  page  152)  and,  what  is 
still  more  important,  insufficient  aspiration  of  the  venous 
blood  and  of  the  lymph-stream,  especially  in  the  skull, 
are  produced. 

It  is  this  interference  with  the  circulation  that  is  often 
responsible  for  symptoms  which,  as  they  are  the  only  ones 
complained  of,  are  apt  to  cause  the  original  nasal  affection 
to  be  overlooked.  A  feeling  of  fulness  and  heat  in  the 
head ;  pressure  in  the  head,  sometimes  aggravated  to 
actual  pain  ;  disinclination  to  work ;  psychic  depression 
or  actual  mental  confusion  ;  inability  to  concentrate  one's 
thoughts, — aprosexia, — diminished  resistance  to  influences 
affecting  the  vascular  system,  such  as  psychic  emotions, 
alcohol,  tobacco,  and  "penetrating"  odors,  manifesting 
itself  in  exacerbation,  especially  of  the  head  symptoms — 
such  are  the  most  important  phenomena  which  but  too 
often  are  incorrectly  interpreted.  To  these  are  added 
actual  pain  localized  in  the  face  or  in  the  head  in  the 
form  of  "  neuralgia,"  or  pains  of  a  paroxysmal  character 
in  the  form  of  true  attacks  of  "  migraine,"  which  are  so 
apt  to  be  provoked  by  vasomotor  disturbances  affecting 
definite  and  usually  inflamed  regions  in  the  interior  of  the 
nose,  more  even  than  by  venous  stasis,  which,  it  is  true, 
always  acts  as  a  predisposing  factor.  All  the  other 
"  reflex  neurotic  "  phenomena  that  accompany  nasal  affec- 
tions depend  on  a  similar  mixture  of  impressions. 

In  infants,  mouth-breathing  may  be  directly  dangerous 
to  health,  if  not  to  life.  Being  forced  to  keep  the  mouth 
closed  for  considerable  periods  at  a  time,  instead  of  only 
at  intervals,  they  are  unable  to  breathe  through  the 
mouth,  although  they  have  no  other  way  of  breathing  if 
the  nose  is  obstructed,  and  thus,  in  order  to  satisfy  their 
air-hunger,  refuse  to  nourish  themselves.     If  the  irapedi- 


SYMPTOMS.  27 

ment  persists,  tlie  infant  speedily  dies,  unless  the  ques- 
tionable expedient  of  artificial  feeding  with  a  spoon  or 
the  stomach-tube  is  resorted  to.  The  accumulation  of 
carbonic  acid  gas  in  the  brain,  which  often  takes  place 
in  mouth-breathing  children  during  sleep,  is  also  the 
cause  of  those  mysterious  attacks  of  pavor  nocturnus  in 
which  the  child  is  suddenly  roused  from  sleep  with  a  loud 
outcry,  and  is  also  the  almost  exclusive  cause  of  nocturnal 
enuresis,  the  sensory  nerve-channels  being  dulled  to  such 
an  extent  that  the  irritation  of  the  accumulated  urine  is 
insufficient  to  wake  the  sleeper  and  merely  produces  reflex 
relaxation  of  the  sphincters. 

The  occurrence  of  epilepsy  of  nasal  origin  in  children 
cannot  be  doubted.  Its  origin  in  impaired  nutrition  of 
the  brain  and  its  membranes  is  quite  intelligible  if  we 
consider  the  effect  of  disturbances  in  the  circulation  at 
the  base  of  the  brain  on  the  frontal  lobes,  where  in- 
flammatory diseases  are  very  prone  to  produce  epileptic 
phenomena. 

The  character  of  the  nasal  secretion  is  a  symptom  of 
importance  in  nasal  disease.  Under.normal  circumstances 
there  is  no  discharge  from  the  nose,  a  fact  that  is  in  oppo- 
sition to  the  popular  conception  of  normal  discharges. 
The  scanty  secretion  produced  by  the  various  irritants  of 
civilized  life — dust,  smoke,  and  the  like — is  readily  dis- 
tinguished from  a  morbid  secretion  by  its  grayish-black 
color,  due  to  the  admixture  of  these  foreign  substances. 
In  many  cases,  especially  in  recent  catarrhs,  pure  water  is 
discharged.  As  a  matter  of  fact,  this  is  not,  as  a  rule, 
pure  serum,  but  a  very  watery  mucus,  as  evidenced  by 
the  fact  that  it  may  be  drawn  out  in  threads  even  when 
it  is  greatlv  diluted.  When  more  or  less  leukocytes  or 
mucin  are  present,  the  secretion  assumes  greater  consist- 
ency and  deeper  color  :  grayish,  tenacious  masses  of  mucus 
alternate  with  thin,  yellow,  creamy  pus ;  firm,  yellowish- 
green  lumps  are  replaced  by  discolored  hard  crusts ;  an 
admixture  of  blood  not  infrequently  appears  as  a  hemor- 
rhage, due  to  diapedesis  or  a  complicating  traumatism. 


28  GENERAL  REMARKS  ON  PATHOLOGY. 

The  inspired  air,  and  still  more  frequently  the  dis- 
charges, are  often  very  offensive,  the  odor  being  due  in 
every  instance  to  saprophytic  decomposition  of  the  secre- 
tion or  of  necrotic  shreds  of  tissue,  whi(!h  in  themselves 
are  without  odor.  The  character  of  the  secretion  in  indi- 
vidual diseases  will  be  discussed  in  the  appropriate 
sections. 

Permanent  mouth-breathing  exerts  a  special  effect  on 
the  ear.  Normally,  the  opening  of  the  tube  whicii  accom- 
panies every  act  of  deglutition  establishes  comnnmication 
between  the  external  ear  and  the  middle  ear,  thereby 
securing  a  permanent  equilibrium  between  the  air-pressure 
on  both  sides  of  the  drum-head.  But  in  nasal  obstruction 
an  insufficient  amount  of  air  or  no  air  at  all  is  able  to 
enter ;  the  air  within  the  middle  ear  is  absorbed,  and  the 
pressure  is  permanently  diminished.  The  result  is  im- 
paired mobility  and  retraction  of  the  drum-head  and 
deafness.  But  there  is  another  danger  which,  though  less 
frequent,  is  even  greater :  a  tubal  orifice  may  be  partly 
open,  or,  if  the  nasal  obstruction  is  not  excessive,  may 
retain  its  normal  valve-like  function  and  the  expired  air 
may  thus  penetrate  to  the  middle  ear  when  the  individual 
blows  his  nose,  even  if  the  act  is  performed  in  a  rational 
manner  (see  p.  22).  In  this  way  hyperemic  conditions 
in  the  middle  ear  are  produced  iii  the  course  of  acute 
catarrhs  and  during  the  exanthemata ;  or  infectious  mate- 
rial from  the  masses  of  secretion  almost  always  present 
in  an  obstructed  nose  may  be  directly  introduced  and 
lead  to  the  production  of  otitis  media. 

The  changes  in  the  skin  and  in  the  eye  frequently 
observed  as  the  secondary  result  of  nasal  disease  are  due 
not  to  transportation  of  the  infection,  but  to  propagation 
of  the  inflammatory  process.  In  children  even  acute 
catarrh  is  accompanied  by  marked  inflammation  of  the 
upper  lip,  and  if  a  chronic  hypersecretion  is  superadded, 
eczema  and  crust-formation  commonly  result.  The  glan- 
dular tissue  of  the  upper  lip  becomes  swollen,  and  the 
characteristic  thickening  of  the  nose  and  lip,  with  secon- 


SYMPTOMS.  29 

dary  swelling  of  the  lymph-glands  at  the  angle  of  the 
jaw,  combine  with  eczema  of  the  eyelids  and  keratitis  to 
produce  the  well-known  picture  of  scrofula.  Not  infre- 
quently tubercle  bacilli  enter  the  lynipii-passages  and 
establish  themselves  in  the  glands,  although  the  skin 
itself  may  not  be  speciiically  involved.  In  adults  sycosis 
of  the  upper  lip  is  more  likely  to  develop  from  the  con- 
stant maceration  and  the  irritation  produced  by  rubbing 
the  infectious  nasal  secretion  into  the  mustache,  and  unless 
the  cause  is  removed,  the  condition  is  never  cured. 

In  the  eye  it  is  the  lacrimal  apparatus  that  most  com- 
monly participates  in  nasal  affections.  Even  the  irrita- 
tion attendant  upou  introducing  a  speculum  or  probe  into 
the  interior  of  the  nose  is  immediately  followed  by  reflex 
lacrimation  in  the  eye  of  the  same  side,  and,  in  a  similar 
way,  swelling  at  the  orifice  of  the  lacrimonasal  duct  in 
the  inferior  nasal  meatus  may  lead  to  obstruction  of  the 
lacrimal  flow  and  lacrimation.  An  inflammatory  process 
may  also  follow  an  ascending  course  through  the  lacri- 
monasal canal,  and  produce  conjunctivitis.  Chronic  in- 
flammation of  the  eyelids  is  practically  always  to  be 
attributed  to  a  latent  nasal  disease.  Phlyctenular  kera- 
titis, often  of  a  very  grave  type,  so  commonly  follows 
chronic  nasal  suppurations  in  children  that  the  causal 
connection  between  the  two  conditions  cannot  be  doubted. 
As  has  been  pointed  out,  keratitis  forms  part  of  the 
symptom-complex  of  scrofula,  which,  as  we  have  seen,  is 
usually  of  nasal  origin.  The  purulent  form  of  dacryo- 
dochitis,  with  its  consequences,  stenoses  and  hypertrophies, 
is  almost  invariably  due  to  nasal  suppuration,  although  it 
can  be  treated  independently  of  the  latter  condition. 

Certain  less  common  and  more  profound  disturbances 
of  the  eye,  such  as  iritis,  glaucoma,  orbital  abscess,  and 
the  like,  occasionally,  but  not  regularly,  exhibit  a  causal 
connection  with  the  nose.  On  the  other  hand,  subjective 
asthenopic  phenomena  are  more  commonly  to  be  attrib- 
uted to  the  variety  of  headaches  characteristic  of  nasal 
disease.     In  such  cases  eye-strain  first  excites  the  symp- 


30  GENERAL  REMARKS  ON  PATHOLOGY. 

toni-complex  that  we  attriliute  to  nasal  disease,  and  a 
feeling  of  fatigue  and  diminished  optic  receptivity  rapidly 
develop  in  the  same  way  as  when  errors  of  refraction  are 
insufficiently  or  improperly  corrected. 

Pharyngeal  and  laryngeal  symptoms  form  an  integral 
part  of  chronic  nasal  affections.  Chronic  pharyngeal 
catarrh  in  the  great  majority  of  cases  is  merely  a  masked 
symptom  of  nasal  hypersecretion.  As  the  secretions  are 
discharged  only  posteriorly*,  their  effects  become  apparent 
on  the  posterior  wall  of  the  pharynx  and  soft  palate.  The 
habit  of  hawking  and  clearing  the  tiiroat  in  the  morning, 
and  the  laborious  clearing  of  the  nostrils  by  a  forced  in- 
spiration, followed  by  expectoration,  can  be  attributed 
only  to  nasal,  or  more  correctly  postnasal,  processes. 
Chronic  laryngeal  catarrh  very  frequently  is  also  due 
simply  to  the  hawking  and  the  attendant  abuse  of  the 
vocal  cords,  and  in  part  to  direct  maceration  of  these 
structures  by  the  tough,  purulent  nasal  secretion  contain- 
ing densely  adherent  crusts.  Sometimes  very  character- 
istic pictures  are  produced  in  this  way,  which  are  repro- 
duced elsewhere  (see  Atlas  of  Diseases  of  the  Larynx). 
Even  without  this  direct  injury  to  the  mucous  membrane 
the  quality  of  the  voice  is  impaired,  especially  if  nasal 
obstruction  occurs  in  early  youth.  Owing  to  insufficient 
resonance  the  individual  muscles  of  the  larynx  are  injured 
by  overexertion  in  the  attempt  to  phonate  distinctly. 

The  rare,  and  usually  severe,  sequels  of  proximal  infec- 
tion or  metastasis  will  be  discussed  later  in  a  special 
chapter.  Of  secondary  importance  are  the  disturbances 
of  the  sense  of  smell,  although  a  good  many  patients  find 
them  exceedingly  troublesome.  Mechanical  anosmia  is 
observed  both  in  total  obstruction  of  the  nose  and  in 
those  forms  of  partial  obstruction  in  which  the  access  of  air 
to  the  olfactory  region  is  interfered  with  or  completely 
blocked.  Accordingly,  they  include  chiefly  tumors  and 
inflammations  in  the  domain  of  the  middle  meatus.  The 
access  of  the  odor-laden  air  to  the  olfactory  membrane 
may  also  be  mechanically  impeded  by  secretions  dropping 


EXAMINATION.  31 

down  from  above,  which  at  the  same  time  exert  a  directly 
deleterious  influence  on  the  membrane.  Anosmia  of 
ozena  patients  is  in  part  due  to  the  fact  that,  although  the 
air  which  is  drawn  into  the  abnormally  dilated  inferior 
meatus  becomes  laden  with  the  odors  that  are  so  offensive 
to  another  person,  it  never  comes  in  contact  with  the 
olfactory  membrane,  and  can,  therefore,  produce  no  olfac- 
tory sensation  in  the  patient  himself.  In  addition,  the 
anosmia  in  many  cases  of  this  kind  is  aggravated  by 
atrophy  of  the  olfactory  cells.  Hence,  if  the  ozena  is 
cured,  the  sense  of  smell  can  be  restored  only  if  some  of 
the  organs  of  smell  are  preserved,  and  the  course  of  the 
inspired  air  can  be  brought  to  follow  the  normal  courses — 
that  is  to  say,  complete  restoration  of  the  sense  of  smell 
is  rarely  attained.  In  the  case  of  inflammations  and 
tumors  the  prognosis,  though  still  doubtful,  is  very  much 
better. 

Parosmia  sometimes  occurs  in  acute  nasal  suppurations, 
especially  during  influenza.  All  other  varieties  probably 
rest  exclusively  on  hysteric,  neurasthenic,  or  other 
psychogenic  foundation.  . 

Subjective  cacosmia  is  always  a  sign  of  a  latent  decom- 
position process  in  the  pharynx,  nasopharynx,  or,  most 
frequently,  in  one  of  the  accessory  sinuses,  and  every 
effort  must  be  employed  to  search  out  the  seat  of  this 
putrefactive  process.  The  source  may  be  incorrectly  re- 
ferred by  the  patient  sometimes  to  the  exterior,  but  the 
condition  never  occurs  without  some  objective  reason. 

Examination. — This  should  begin  with  simple  ocular 
inspection.  A  good  deal  of  valuable  information  is  often 
to  be  gathered  from  the  patient's  face  :  the  expression  ; 
the  lines  about  the  nose  and  mouth ;  the  external  charac- 
ter of  the  nose,  lips,  region  of  the  jaw,  and  neck — are  often 
very  significant.  The  mouth,  too,  should  at  first  be  in- 
spected without  the  aid  of  the  hands  or  instruments.  The 
teeth,  the  tongue,  and  the  gums  are  first  subjected  to  in- 
spection. If  the  surgeon  is  looking  for  syphilitic  infec- 
tion in  the  mouth,  he  must  not  neglect  to  note  the  condi- 


32  GENERAL  REMARKS   ON  PATHOLOGY. 

tion  of  the  inner  surface  of  the  cheeks  and  lips,  and  the 
floor  of  the  mouth  undcnieatli  the  tongue.  For  this  pur- 
pose the  moutii-liook  shown  in  the  accompanying  figure 
(Fig.  4)  will  be  found  useful.  After  this  has  been  done, 
a  tongue-depressor  is  used,  and  the  soft  palate  and  poste- 
rior pharynx  are  inspected.  In  ordinary  cases  a  common 
flat  tongue-depressor  like  a  paper-(!Utter  with  blunt  edges 
answers  every  purpose.  If  the  tongue  offers  unusual  re- 
sistan(!e,  this  is  best  overcome  by  means  of  an  instrument 
bent  at  riglit  angles,  like  that  devised  by  FrJinkel,  or  by 
means  of  Tiirck's  tongue-depres.sor,  which  comes  in  three 
sizes,  and  which  may  be  held  by  the  patient  if  the  sur- 
geon has  to  use  both  hands.  Reflex  choking  is  overcome 
by  exerting  firm,  uniform  pressure  on  the  tongue,  taking 
care  that  the  instrument  does  not  extend  as  far  as  the  base. 


Fig.  4.— Mouth-hook  (one-half  size). 

Ordinary  daylight  arranged  so  as  to  fall  over  the  ex- 
aminer's shoulder  suffices  for  inspecting  the  pharynx.  In 
the  evening,  and  when  the  nasopharynx  is  to  be  examined, 
an  artificial  source  of  light  placed  between  the  eye  and 
the  object  is  necessary.  As  posterior  rhinoscopy  j)articu- 
larly  requires  central  vision, — i.  e.,  adjustment  of  the 
visual  axis  approximately  in  the  line  of  the  incident  rays 
of  light, — it  is  best  to  use  a  reflector  with  a  central  open- 
ing, which  should  be  adjusted  exactly  in  front  of  the  sur- 
geon's eye.  The  light,  which  is  derived  from  any  suit- 
able lamp,  is  thus  thrown  into  the  throat  and  on  the  small 
rhinoscopic  mirror.  The  luminous  source  may  be  direct 
sunlight,  or,  what  is  better,  sunlight  reflected  by  a  con- 
cave mirror  fastened  to  the  window,  or  any  sufficiently 
powerful  artificial  illumination.  The  electric  incandescent 
lamp,  which  is  adjusted  between  the  eyes,  is  quite  appro- 


EXA3nNATI0X. 


33 


priate  in  ordinary  cases,  but  on  account  of  its  unavoidable 
size  it  sometimes  prevents  the  surgeon  from  seeing  as  far 
down  as  necessary,  and  does  not  permit  of  central  vision, 
which  appears  to  be  indispensable  for  the  inspection  of  very 
narrow  passages.  The  reflector  or  electric  incandescent 
lamp  may  be  fastened  to  the  head  with  a  strap  or  metal 


Fig.  5.— Stationary  reflector. 


frame  for  ambulant  practice  or  occasional  examinations 
at  the  office.  For  one  who  does  a  great  deal  of  this  work, 
however,  the  stationary  reflector,  illustrated  in  Fig.  5, 
which  automatically  fixes  itself  in  any  desired  position, 
will  prove  more  useful.  The  author  has  used  it  during  a 
practice  extending  over  many  years.      The  rhinoscopic 


34  GENERAL  REMARKS  ON  PATHOLOGY. 

mirror,  which  should  be  warmed  or  immersed  in  a  solu- 
tion of  lysol  to  prevent  its  being  dimmed  by  the  patient's 
breath,  must  be  carried  directly  behind  the  uvula,  with- 
out touching  anywhere,  and  placed  in  such  a  position 
that,  by  turning  it  in  various  directions,  a  complete  image 
of  the  nasopharynx  and  of  the  choanae  is  obtained. 

The   necessary  relaxation   of    the    soft   parts   is  best 
achieved  by  having  the  patient  breathe  quietly  in  and  out. 


Fig.  6.— Image  obtained  by  posterior  rhinoscopy :  R,  Rosenmiiller's  fossa ; 
Ch,  choanse ;  w,  tubal  fold ;  o,  tubal  orifice ;  /,  fornix  or  vault ;  /?,  septum ;  u, 
uvula;  V,  soft  palate;  sp,  salpingopharyngeal  fold  (posterior  pillar);  pp  and 
pg,  i>alatopharyngeal  and  palatoglossal  arch. 

Most  people  merely  contract  the  soft  palate  when  they 
are  told  to  hold  their  breath.  If  the  patient  continues  to 
contract  the  soft  palate  nervously,  he  should  be  told  to 
snore,  the  surgeon,  if  necessary,  giving  him  an  object- 
lesson.  The  practice  of  asking  a  patient  to  intone  a  nasal 
sound,  such  as  the  French  nasal  "n,"  is  impracticable, 
since  the  patient  generally  does  it  wrong,  and  thus  brings 
about  the  very  thing  that  the  surgeon  wishes  to  avoid — 
namely,  shutting  off  of  the   pharyngeal  from   the  oral 


EXAMINATION.  35 

cavity.  I  do  not  recommend  using  any  instrument  for 
drawing  down  the  soft  palate,  except  in  very  rare  cases. 
For  my  part  I  have  always  been  able  to  dispense  with 
instruments.  A  practised  examiner  can  do  without  them, 
and  an  unskilful  one  will  derive  no  benefit  from  them. 

It  may  be  said  that  posterior  rhinoscopy  requires  not 
only  constant  practice,  but  a  certain  art  dependent  upon 
individual  skill.  Introducing  the  instrument  fearlessly, 
and  at  the  same  time  delicately,  and  seizing  the  favorable 
moment  with  lightning  rapidity,  will  bring  success  under 
the  most  difficult  circumstances.  But  even  the  most 
skilful  and  careful  examiner  will  not  always  find  this 
method  practicable.  Although,  according  to  the  author's 
experience,  about  95  per  cent,  of  all  individuals  can  be 
examined  rhinoscopically,  there  are  5  per  cent.,  consist- 
ing chiefly  of  children,  who  are  more  or  less  intractable. 
As  in  the  latter  the  condition  that  we  have  to  deal  with, 
in  the  great  majority  of  cases,  is  a  tumor  in  the  naso- 
pharynx, the  surgeon  can  find  out  by  palpation  what  he 
was  unable  to  make  out  by  inspection.  Even  in  adults 
palpation  is  sometimes  necessary  to  determine  the  length 
of  foreign  bodies,  of  a  sequestrum,  of  a  tumor,  or  the  like. 
The  surgeon  stands  behind  the  patient,  who,  if  he  is  an 
adult,  may  sit  down  ;  if  he  is  a  child,  he  is  held  lightly 
between  the  surgeon's  knees,  his  hands  being  at  the  same 
time  secured  by  a  third  person,  merely  to  guard  against 
premature  resistance.  As  soon  as  the  patient  opens  his 
mouth,  the  mucous  membrane  of  the  cheek  is  forced  in 
between  the  teeth  with  the  right  forefinger,  while  the  head 
is  at  the  same  time  securely  held  against  the  examiner's 
chest.  By  this  means  the  patient  is  ])revented  from  closing 
his  mouth  and  also  from  biting.  The  examining  finger, 
which  then  requires  no  protection,  is  passed  rapidly  back 
along  the  hard  palate,  and  to  one  side  of  the  uvula,  be- 
hind the  soft  palate,  which  is  usually  tensely  contracted. 
The  choanse,  the  roof  of  the  pharynx,  and  its  lateral 
walls  are  palpated  as  rapidly  as  possible  to  avoid  pro- 
longing the  unpleasant  process  any  more  than  is  neces- 


36  GENERAL  REMARKS  ON  PATHOLOGY. 

sary.  It  liardly  needs  to  be  said  that  tlio  nail  of  the 
examining  finger  must  be  trimmed  quite  close,  and  that 
the  hand  must  be  washed  before  it  is  introduced  into 
the  mouth.  Any  substance  brought  out  with  the  finger 
is  then  carefully  examined  by  inspection  and  palpation. 
In  the  examination  of  the  nose,  central  reflected  light 
is  practically  always  required.  The  light  is  first  thrown 
on  the  vestibule  of  the  nose,  which  is  examined  without 
the  use  of  an  instrujpent  by  merely  raising  the  tip.  Next 
a  speculum  is  inserted  in  front,  between  the  cutaneous 
septum  and  the  al^  of  the  nose,  which  brings  the  anterior 


Fig.  7.— Rhinoscopic  image  of  the  right  half  of  the  nose:  m-m,'.  Middle; 
«-«',  inferior  turbinate;  mg,  middle;  ug,  inferior  meatus;  (<,  septum.  The  il- 
lustration has  been  constructed  from  several  images  obtained  with  the  head 
turned  slightly  to  the  righ^, 

angle  of  the  vestibujt?  into  view.  The  instrument  is  then 
introduced  farther  jpto  the  nose  with  the  blades  closed, 
and  after  its  complete  introduction,  the  blades  are  sep- 
arated gently.  The  procedure  ought  not  to  be  followed 
by  hemorrhage  except  in  very  rare  conditions,  such  as 
hemophilia  and  the  )ike.  The  different  makes  of  spec- 
ula are  legion  ;  the  j^uthor  is  in  the  habit  of  using  the 
old  Kramer  instrumej^t  exclusively.  The  position  of  the 
speculum  should  never  be  altered,  but  the  surgeon  lays 
his  hand  on  the  patient's  head  and  gently  turns  it  for- 
ward and  backward,  or  the  head  may  be  placed  in  a  rather 
uncomfortable  position  of  backward  extension,  so  as  to 


EXAMINATION.  37 

enable  the  examiner  to  obtain  a  full  view  of  the  interior 
of  the  nose  from  the  floor  to  the  roof.  If  any  doubt 
remains  as  to  the  position,  attachment,  resistance,  or  other 
factors  in  connection  with  any  object  seen  within  the  nose, 
or  if  it  is  desired  to  follow  up  an  opening,  a  probe  is 
brought  into  use.  In  most  cases  the  tip  has  to  be  bent  at 
an  angle.  The  probe  should  always  be  handled  with  the 
greatest  lightness  and  delicacy,  both  to  avoid  inflicting 
an  injury  and  to  guard  against  errors.  Its  special  uses 
will  be  discussed  farther  on.  If  there  is  any  secretion 
in  the  nose,  the  patient  is  told  to  blow  his  nose,  or  it 
may  be  wiped  out  carefully  with  a  narrow  pledget  of 
cotton  held  in  the  nasal  forceps.  Secretion  on  the  floor 
of  the  nose  is  often  difficult  to  remove  by  wiping  out 
from  behind  forward,  because  it  may  be  lodged  in  a  deep 
depression.  Dry  crusts  are  frequently  so  firmly  adherent 
that  they  cannot  be  removed  without  producing  a  hemor- 
rhage ;  in  such  cases  they  should  be  covered  for  several 
hours  with  a  cotton  tampon,  after  which  they  will  readily 
come  away,  as  they  have  been  macerated  by  the  after- 
coming  secretion,  which,  owing  to  the  irritation  of  the 
foreign  body,  is  more  Avatery  than  usual.  Crusts  may  also 
be  softened  with  an  ointment. 

To  examine  the  contents  of  the  antrum,  an  exploratory 
opening  is  made  with  a  heavy,  firm  trocar.  [A  trocar 
and  cannula  curved  through  not  quite  a  quarter  of  a 
circle  enables  the  puncture  to  be  made  the  more  easily, 
as  with  such  an  instrument  entrance  is  effected  more 
nearly  at  a  right  angle  to  the  bony  surface  of  the  inner 
antral  wall  under  the  inferior  turbinate.  With  a  straight 
instrument  there  is  some  danger  of  slipping  under  the 
mucosa  and  not  entering  the  cavity. — Ed.]  After  anes- 
thetizing the  depression  underneath  the  anterior  extremity 
of  the  inferior  turbinate  (see  Fig.  2)  with  a  20  per  cent, 
solution  of  cocain,  the  cartilaginous  portion  of  the  sep- 
tum is  bent  to  one  side,  the  trocar  applied  as  vertically  as 
possible  to  the  bone  immediately  below  the  region  of  the 
turbinal    bone,  and    introduced  into    the   cavity    by   an 


38  GENERAL  REMARKS  ON  PATHOLOGY. 

auger-like  movement.  The  bone  in  this  region  is  usually 
as  tiiin  as  paper,  and  the  trocar  can  be  introduced  very 
easily.  In  rare  cases  the  bone  is  thicker  and  more  re- 
sistant, sometimes  making  it  impossible  to  introduce  the 
trocar.  As  soon  as  the  operator  feels  that  the  point  has 
entered  the  cavity,  the  point  is  withdrawn  and  the  can- 
nula inserted  a  little  further,  in  order  to  make  sure  that 
the  trocar  has  not  entered  the  opposite  outer  wall  of  tlie 
cavity.  A  speculum  is  then  introduced,  the  middle 
meatus  being  kept  carefully  in  view,  and  a  rubber  bulb 
attached  to  the  cannida  for  the  purpose  of  insufflation. 
This  in  many  cases  will  be  followed  by  the  escape  of 
some  variety  of  secretion  through  the  hiatus  maxillaris. 
If  no  secretion  makes  its  appearance,  a  1  per  cent,  solu- 
tion of  carbolic  acid  is  sprayed  in,  the  patient  holding 
his  head  bent  forward  and  toward  the  opposite  side,  after 
which  the  fluid  that  remains  in  the  cavity  is  rapidly  evac- 
uated and  examined  before  it  has  been  modified  by 
the  after-coming  hemorrhage.  Mucus  floats  on  the  sur- 
face; pus  sinks  to  the  bottom.  If  there  is  reason  to  sup- 
pose that  the  cavity  contains  very  little  secretion,  it  is 
well  to  dam  it  back  by  means  of  a  plug  of  cotton  intro- 
duced in  such  a  way  as  to  obstruct  the  middle  meatus  and 
leave  the  inferior  meatus  free.  The  plug  is  left  in  place 
for  twenty-four  hours.  This  is  especially  necessary  in 
the  case  of  cavities  that  constantly  empty  themselves 
without  accumulating  any  residual  secretion. 

This  method  of  tamponade  is  also  useful  in  determining 
from  what  particular  cavity  a  secretion  takes  its  origin. 

In  examining  the  pneumatic  accessory  sinuses,  trans- 
illumination with  small  incandescent  lamps  is  also  em- 
ployed. The  results  obtained  by  this  method  are  often 
ambiguous ;  obscuration  may  be  due  to  abnormal  position 
or  deficiency  of  a  cavity,  and,  on  the  other  hand,  a  cavity 
that  is  constantly  discharging  may  contain  too  little  secre- 
tion to  intercept  the  light.  The  method  has  a  positive 
value  only  when  a  cavity  which  before  had  been  dark  is 
found   to    be   translucent  aft^r  operation,    which    may, 


TREATMENT.  39 

therefore,  be  presumed  to  have  been  successful ;  other- 
Avise  the  method  is  of  no  value,  except  for  purposes  of 
demonstration,  and  does  not  require  further  notice  in  this 
work,  which  is  solely  devoted  to  practical  considera- 
tions. Radioscopy,  on  the  other  hand,  although  rarely 
indicated,  has  firmly  established  its  claims  in  determining 
the  presence  of  foreign  bodies,  and,  in  many  cases,  the 
coudition  of  the  cavity  as  well.  It  is,  of  course,  absurd 
to  conclude  that  because  regions  containing  pneumatic 
cells  appear  dark  under  R5ntgen-ray  illumination,  a  dis- 
charge is  present,  any  more  than  in  the  case  of  ordi- 
nary transillumination.  But  when,  for  instance,  a  probe 
has  been  introduced  into  the  frontal  sinus,  it  is  unques- 
tionably useful  to  determine,  by  means  of  a  Rontgen-ray 
photograph,  whether  the  probe  really  has  entered  the 
sinus  or  merely  occupies  one  of  the  frontal  ethmoid  cells, 
which  are  often  found  in  a  very  abnormal  position.  The 
presence  of  septa  into  the  cavity,  converting  it  into  sev- 
eral chambers,  may  also  be  determined  by  means  of 
radiography. 

Treatment. — The  treatment  of  diseases  of  the  mouth 
and  pharynx  is  based  on  the  fundamental  principle  that 
all  offensive  and  excessive  secretion  must  be  removed,  so 
as  to  get  rid  of  the  constant  irritation  set  up  by  the 
decomposition  products.  Disinfection  is  possible  only 
under  quite  exceptional  circumstances.  As  a  rule,  it  is 
not  to  be  attempted.  Mouth-washes  and  gargles  should, 
therefore,  be  as  nearly  indifferent  as  possible,  owing  to  the 
danger  of  some  being  accidentally  swallowed,  the  chief 
purposes  that  they  have  to  fulfil  being  to  restrict  secretion 
and  dissolve  the  secretion  already  formed.  The  alkalis 
have  been  found  by  experience  to  accomplish  the  latter 
object  better  than  any  other  substances.  It  is  also  de- 
sirable to  prevent,  as  far  as  possible,  by  means  of  aromatic 
substances,  the  distressingly  bad  taste  in  the  mouth.  In 
health  the  mouth  and  throat  can  usually  be  cleansed  suf- 
ficiently with  cold  water.  Cleansing  of  the  teeth  does 
not  require  any  special  tooth-powder,  but  the  tooth-brush 


40  GENERAL  REMARKS  ON  PATHOLOGY. 

should  be  of  the  proper  shape — not  concave  and  not  too 
hard.  If  large  masses  of  mucus  are  to  be  removed,  a 
lukewarm  1  per  cent,  solution  of  common  salt  should  l)e 
used.  Mild  grades  of  inflammation  demand  some  astrin- 
gent wash  in  the  form  of  a  warm  1  per  cent,  solution  of 
alum  containing  a  small  amount  of  salt, 

A  useful  mouth-wash  and  gargle  may  be  prepare<l  by 
adding  half  a  teaspoonful   of  the  following   solution  to 


^i     Tinct.  rayrrhae, 

Tinct.  rhatanse,         aa  f  .Iss ; 
Ol.  menth.  pip.,  gtt.  iv. 

Or  the  undiluted  solution  may  be  directly  painted  on  the 
gums.  Severer  grades  of  pharyngitis  may  be  alleviated 
by  gargling  with  warm  or  hot  solutions,  preferably  infu- 
sions of  sage  or  chamomile  tea.  Ice  pellets  and  ice-cold 
gargles,  which  are  so  popular  with  some  })cople,  should 
be  forbidden.  The  momentary  anemia  produced  by  the 
cold  is  followed  by  a  corresponding  engorgement  of  the 
relaxed  arterial  vessels,  whereas  a  warm  application  pro- 
duces a  lasting  passive  hyperemia,  and  therefore  acts  as 
a  better  derivative  from  the  inflamed  areas.  Externally 
the  same  object  may  be  accomplished  by  means  of  a  moist 
warm  throat  compress,  whicli  in  diseases  aifecting  the 
glandular  region  is  not  to  be  applied  around  the  throat, 
as  it  fails  to  reach  the  angle  of  the  jaw,  but  rather  under 
the  chin,  and  fastened  on  the  top  of  the  head,  as  in 
Fig.  8.  As  the  bandage  applied  in  this  way  covers  the 
ears,  the  compress  itself — that  is,  the  wet  cloth  and  im- 
permeable covering — must  not  extend  higher  than  the 
lobes  of  the  ears,  so  that  the  latter  are  covered  only  by 
the  dry  bandage.  In  every  acute  disease  of  the  upper 
mucous  membrane  especial  attention  must  be  given  to  the 
condition  of  the  bowels,  a  mild  or  even  a  powerful  lax- 
ative being  administered  at  the  very  beginning  of  the 
attack.      In  chronic  inflammations  of  this  region,  also, 


TREATMENT. 


41 


the  digestion  must  be  carefully  looked  after.  The  patient 
should  be  in  a  room  that  is  free  from  dust,  and  the  air 
should  not  be  too  warm,  nor,  if  possible,  too  dry.  For 
the  same  reason  mild  sea-climate  and  moist  forest  regions 
are  to  be  recommended  as  resorts.  If  the  patient  wants 
to  get  well  rapidly,  he  must  give  up  tobacco ;  in  any  event, 
chewing  and  taking  of  snuff  must  be  prohibited. 

^^  ounds  in  the  oral  cavity  and  in  the  nose  should  be 
dressed,  if  necessary,  with  iodoform  or  nosophen  gauze, 


Fig.  8. 


the  only  disinfectants  of  mucous  membranes  that  have 
proved  themselves  absolutely  reliable.  After  extraction 
of  a  tooth,  and  particularly  when  several  teeth  have  been 
extracted,  the  alveoli  should  be  packed  with  a  small  strip 
of  gauze,  which  is  allowed  to  remain  until  the  following 
day.  After  operative  wounds,  such  as  the  wound  made 
in  opening  the  antrum,  and  after  any  accidental  injuries, 
especial  care  must  be  exercised  to  pack  the  pockets  that 
tend  to  form  in  the  loose  connective  tissue,  especially  of 


42  GENERAL  REMARKS  ON  PATHOLOGY. 

the  mucous  membrane  covering  the  cheeks.  If  this  pre- 
caution is  neglected,  dangerous  abscesses  may  result.  The 
disagreeable  taste  of  iodoform  in  the  mouth  may  be  over- 
come advantageously  by  means  of  gargles  with  diluted 
"  Waldmeisteressenz "  (botan.,  Asperula,  wood-rowel), 
which  can  be  had  at  any  delicatessen  store.  In  the  nose, 
iodoform  and  packing  with  gauze  may,  as  a  rule,  be  dis- 
pensed with.  The  best  means  to  prevent  infection  in  this 
region  consists  in  operating  in  such  a  way  as  to  leave  a 
broad  open  surface.  Such  surfaces  in  the  mouth  are  suf- 
ciently  cleansed  by  the  movements  of  the  tongue  and  the 
constant  bathing  of  mucus,  and  in  the  nose  by  the  con- 
stant expiratory  air-current,  particularly  as  mucous  mem- 
branes possess  an  extraordinary  tendency  to  heal.  Pack- 
ing in  the  nose,  even  with  aseptic  gauze,  is  more  apt  to  do 
harm  than  good,  on  account  of  the  exceedingly  complex 
arrangement  of  the  cavities,  making  it  practically  impos- 
sible to  avoid  introducing  the  packing  in  such  a  way  as  to 
produce  retention  and  its  disastrous  consequences.  And  yet, 
packing  has  been  used  more  in  the  nose  than  elsewhere — 
namely,  for  the  purpose  of  controlling  hemorrhage. 

Spontaneous  hemorrhages  almost  always  have  their 
origin  in  the  anterior  portion  of  the  nose.  In  the  mouth 
they  are  practically  unknown.  In  most  cases  the  hemor- 
rhage can  be  controlled  by  sitting  with  the  head  slightly 
bent  forward,  so  that  the  blood  continues  to  flow  from 
the  anterior  nares  and  nasal  respiration  is  still  possible. 
The  latter  is  an  important  point,  as  nasal  respiration 
tends  to  unload  the  blood-vessels  of  the  head.  Most 
spontaneous  hemorrhages  cease  of  their  own  accord  in 
this  position,  but  if  the  bleeding  continues,  the  patient 
should  be  told  to  sniif  up  a  few  drops  of  freshly  expressed 
lemon-juice ;  to  apply  a  cold-water  cloth  to  the  nape  of 
the  neck ;  or  to  swallow  a  pinch  of  salt.  If  packing 
really  becomes  necessary,  it  is  to  be  remembered  that  it 
can  arrest  a  hemorrhage  only  when  it  is  applied  to  the 
bleeding  point,  which  in  almost  ever}'  instance  is  found 
in  the  anterior  portion  of  the  nose  (see  p.  15).     There 


TREATMENT.  43 

can  be  nothing  more  senseless  than  the  barbarous  method 
of  packing  the  entire  nasopharynx  with  the  aid  of  a 
Bellocq  cannuhi.  The  nose  shoukl  be  wiped  dry,  where- 
upon the  blood  will  be  seen  issuing  from  a  point  near 
the  anterior  extremity  of  the  septum,  and  permanent 
packing  can  usually  be  dispensed  with  by  applying  a  small 
pledget  of  cotton  saturated  with  peroxid  of  hydrogen 
under  pressure,  and  holding  it  in  position  for  several 
minutes.  If  the  hemorrhage  still  continues,  the  cotton 
compress  is  left  in  place  several  hours,  or  even  until 
the  following  day.  If  the  hemorrhage  has  a  deeper 
origin,  the  indication  to  apply  the  packing  directly  to  the 
bleeding  point  is  even  more  urgent.  It  is  absolutely  use- 
less to  pile  on  the  gauze  in  front  of  the  bleeding  point, 
and  the  resulting  nasal  obstruction  may  even  be  harmful. 
Operative  hemorrhage  should  always  cease  of  its  own 
accord  if  the  operative  wound  is  smooth,  no  fragments 
of  tissue  have  been  left  behind,  and  nasal  respiration 
is  not  interfered  with.  The  hemorrhage  may  be  arrested 
more  rapidly  if  the  operator  desires  to  continue  his  work 
by  the  application  of  a  pledget  of  cotton  saturated  with 
peroxid  of  hydrogen,  but  the  best  and  most  reliable  means 
of  arresting  hemorrhage,  after  operation,  and  especially 
of  preventing  secondary  hemorrhage,  consists  in  doing  the 
work  in  a  cleanly  and  thoroughly  workmanlike  manner, 
so  as  at  least  to  secure  free  nasal  respiration.  The  most 
profuse  hemorrhage — such,  for  instance,  as  occurs  in  noses 
obstructed  with  polypi — ceases  almost  instantly  as  soon  as 
free  ventilation  is  established.  In  such  cases  packing  is 
especially  undesirable,  because  of  the  almost  invariable 
presence  of  pus,  which  under  the  most  favorable  circum- 
stances is  sure  to  infect  the  wound.  Even  fatal  results 
have  been  recorded  from  the  retention  of  pus  behind 
the  tampon. 

One  of  the  chief  indications  in  the  treatment  of  nasal 
disease  is  to  secure  free  escape  for  the  excessive  secretion. 
Although  it  may  not  effect  a  cure, — and  this  is  often  im- 
possible, even  in  comparatively  mild  cases,  speaking  from 


44  GENERAL  REMARKS  ON  PATHOLOGY. 

a  pathologic  point  of  view,  without  serious  surgical  inter- 
vention,— perfect  drainage,  by  relieving  the  deeper  air- 
passages  from  the  injurious  influence  of  the  secretions, 
often  suffices  to  remove  a  deep-seated  trouble,  or  at  least 
to  render  it  latent.  This  is  accomplished  in  the  first  place 
by  frequent  and  rational  cleansing  of  the  nose  (see  p. 
22).  Chihlren  need  constant  admonition  in  this  respect, 
as  their  noses  are  often  filled  with  secretion  which,  although 
a  day  old,  is  readily  expelled  by  blowing. 

[The  question  of  hemorrhage  from  the  nose,  whether 
spontaneous  or  induced  by  any  variety  of  trauma,  surgical 
or  otherwise,  suggests  the  mention  here  of  a  new  thera- 
peutic agent  which  is  a  most  valuable  addition  to  our 
resources.  It  is  the  active  principle  of  the  suprarenal 
gland,  which  has  been  variously  named.  For  a  while  the 
saccharated  extract  was  employed,  it  being  mixed  with 
distilled  water  and  then  filtered.  For  convenience  of 
use,  however,  it  has  been  superseded  by  the  commercial 
"adrenalin,"  which  is  a  solution  of  the  muriate  of  the 
active  principle,  1  part  to  1000  of  normal  sodium  chlorid 
solution,  preserved  by  the  addition  of  0.5  per  cent,  of 
chloretone.  This  may  be  diluted  several  times  with  its 
bulk  of  water,  and  yet  be  strong  enough  for  all  practical 
purposes. 

It  is  not  too  much  to  say  that  the  value  to  the  rhinolo- 
gist  of  this  remedy  is  second  only  to  that  of  cocain.  Its 
hemostatic  properties  are  little  short  of  marvelous.  It 
acts  on  the  unstriped  muscular  fiber  of  the  vessel-walls. 
(Cocain  constringes  through  the  medium  of  the  vasomotor 
nerves.)  The  adrenalin  may  be  used  in  the  same  solu- 
tion with  cocain,  though  we  prefer  to  use  the  two  sepa- 
rately, the  cocain  preceding.  Adrenal  is  not  itself  dis- 
tinctly anesthetic.  It  quickly  blanches  the  mucosa,  and 
Avith  the  combined  use  of  the  two  remedies  named,  we 
can  render  the  operative  field  anesthetic  and  bloodless ; 
in  other  words,  can  obtain  ideal  conditions  for  operating 
quickly,  safely,  and  agreeably. 

Concerning  the  physiologic  office  of  this  agent  in  the 


TREATMENT.  46 

human  body,  it  may  be  said  that  it  is  supposed  to  assist 
in  maintaining  the  normal  blood-pressure.  It  quickly 
revives  a  flagging  heart,  even  when  merely  dropped  on  a 
normal  raucous  surface.  For  a  longtime  it  was  supposed 
that  it  was  decomposed  in  its  passage  through  the  gastro- 
enteric canal.  Testimony  on  this  point  is  still  somewhat 
conflicting.  But  tiie  results  obtained  in  many  cases  of 
the  hay-fever  type  seem  to  suggest  the  view  that  it  is  not 
so  decomposed.  The  adrenalin  solution  can  be  repeatedly 
sterilized  without  any  alteration  of  its  hemostatic  effect. 

Obviously,  after  the  use  of  so  powerful  an  agent  there 
must  come  a  strong  vascular  reaction,  and  the  question 
has  been  much  discussed  as  to  whether  secondary  hemor- 
rhage following  operations  in  Avhich  adrenalin  has  been 
employed  is  more  common  than  formerly.  Here,  again, 
there  is  a  conflict  in  clinical  testimony.  So  far  as  differ- 
ing views  on  this  point  have  been  collated,  there  is  a 
preponderance  in  favor  of  the  likelihood  of  more  frequent 
bleeding. 

Another  disadvantage  of  the  remedy,  and  one  that  in 
any  given  ease  cannot  be  foreseen,  is  that  an  idiosyncrasy 
following  its  use  occasionally  produces  a  violent  reaction 
in  non-operative  cases — as,  for  instance,  when  it  is  em- 
ployed to  check  an  incipient  coryza.  Often  the  reaction 
with  violent  sneezing  and  nasal  occlusion  renders  the 
patient's  last  sta;te  worse  than  his  first.  Several  cases 
have  been  reported  of  edema  of  the  palate,  pharynx,  and 
epiglottis  following  the  application  of  the  remedy  to  the 
throat.  In  these  cases  scarification  has  been  followed  by 
relief.     Constitutional  symptoms  have  been  wanting. 

Finally,  it  may  be  said  that  the  remedy  has  been  found 
to  be  of  service  in  all  commencing  inflammations  of  the 
upper  air-tract,  where  circumstances  permit  its  direct 
application.  It  will  frequently  abort  a  commencing  laryn- 
gitis. In  the  pharynx  it  will  often  bring  about  a  like 
happy  result,  though  patients  sometimes  complain  of  a 
disagreeable  dryness,  owing  to  its  powerful  constringent 
properties. — Ed.] 


46  GENERAL  REMARKS  ON  PATHOLOGY. 

Next  in  order  is  irrigation.  In  many  cases  a  lukewarm 
physiologic  salt  solution  suffices ;  if  the  secretion  is  tena- 
cious, a  solution  consisting  of  half  a  teaspoonful  each 
of  sodium  chlorate,  sodium  carbonate,  and  sodium  bibo- 
rate  in  ^  liter  (quart)  of  warm  water  may  be  used.  The 
use  of  sprays  and  nasal  douches  is  to  be  discouraged, 
on  account  of  the  danger  of  the  secretions  being  car- 
ried into  accessory  sinuses  and  into  the  ear,  but  the 
patient  may  be  allowed  to  introduce  the  fluid  with  a 
spoon  or  one  of  the  glass  nose-cups  that  can  be  bought  at 
any  store.  Personally,  I  always  have  the  patient  snuff 
up  the  solution  from  the  palm ;  the  advantage  of  this 
method  lies  in  the  fact  that  the  middle  meatus  is  also 
bathed,  as  the  aspirated  fluid  follows  the  same  path  as  in- 
spired air  (see  p.  16),  and  thus,  without  producing  a  dan- 
gerous pressure,  gets  into  the  upper  portions  of  the  nasal 
cavity.  The  excessive  pressure  gives  rise  to  the  sudden 
occurrence  of  headache,  and  the  patient  must,  therefore, 
be  expressly  warned  to  desist  when  this  symptom  declares 
itself.  It  goes  without  saying  that  the  nostrils  must  be 
separately  blown  out  after  each  aspiration  of  fluid. 

To  loosen  hard  crusts  or  to  induce  a  more  serous  secre- 
tion, a  10  per  cent,  solution  of  ichthyol  in  paraffin  or 
liquid  vaselin  may  be  introduced  with  great  advantage. 
The  same  solution  may  be  painted  on  the  throat  if  that 
structure  is  covered  with  crusts.  The  "fluid  ointment" 
may  be  made  of  any  desired  consistency  by  adding  ordi- 
nary vaselin. 

One  of  the  things  that  the  rhinologist  is  most  frequently 
called  upon  to  do  is  to  restore  the  permeability  of  an  ob- 
structed nose.  If  the  obstruction  involves  extensive  por- 
tions of  the  lymphatic  pharyngeal  ring,  the  measures  de- 
scribed in  a  subsequent  section  become  necessary.  In 
the  nose  itself  cauterization  is  the  method  most  frequently 
resorted  to.  The  sovereign  remedy  is  trichloracetic  acid. 
There  is  no  need  of  any  special  applicator;  the  tip  of  a 
protected  probe  is  simply  dipped  into  the  acid,  which, 
on  exposure  to  the  air,  rapidly  becomes  converted  into 


TBEA  TMENT.  Al 

a  tenacious  liquid,  and  the  crystal  or  drop,  as  the  case 
may  be,  which  readily  adheres,  is  carefully  applied  to 
the  proper  spot.  Any  excess  is  at  once  removed  with 
a  cotton-wound  applicator. 

If  a  greater  destruction  of  tissue  is  necessary,  the  gal- 
vanocautery  is  employed.  While  a  flat  application  may 
be  indicated  in  destructive  processes,  it  is  usually  better 
to  insert  the  cautery  more  deeply  into  the  tissues  in 
removing  ordinary  benign  hyperplasias,  which  are  the 
conditions  that  most  frequently  require  treatment;  as  a 
rule,  the  obstruction  is  due  to  hypertrophy  of  the  erectile 
tissue  in  the  inferior  turbinate.  The  point  of  the  cautery, 
which  should  be  red-hot,  is  inserted  through  the  anterior 
naris  into  the  inferior  turbinate,  where  it  at  once  enters 
the  spongy  tissue  ;  the  cautery  is  then  carried  along  the 
bone  as  far  as  possible, — or  as  far  as  may  be  considered 
necessary, — and  then  is  carefully  withdrawn  before  it  is 
cold. 

This  method  is  greatly  preferable  to  superficial  cauteriza- 
tion in  furrows,  which  is  still  recommended  by  many 
authors.  In  the  first  place,  the  instrument  is  applied  to  the 
chief  seat  of  hyperplasia ;  then  it  produces  practically  no 
hemorrhage  and  only  a  very  small  scab  at  the  point  of  in- 
sertion. Hence  no  danger  of  secondary  hemorrhage  after  it 
comes  away.  The  pain  is  insignificant,  and,  what  is  more 
important  than  anything  else,  there  is  no  danger  of  an  adhe- 
sion with  the  septum,  which  is  often  scorched  by  the  radi- 
ating heat  when  the  superficial  method  is  employed.  [A 
valuable  method  of  cauterizing  the  turbinates  is  that  sug- 
gested by  Goldstein,  of  St.  Louis.  He  inserts  a  fine 
trocar  and  cannula  under  the  mucosa,  passing  them  along 
any  desired  distance.  The  trocar  is  then  withdrawn  and 
replaced  by  a  small  probe  of  the  same  size,  on  the  end 
of  which  is  fused  chromic  acid.  The  end  of  the  probe 
projects  a  little  beyond  the  cannula.  The  entire  appa- 
ratus is  then  withdrawn  so  that  a  linear  submucous  cauter- 
ization is  made. — Ed.] 

After  the  galvanocautery  has  been  used  in  the  nose,  an 


48  GENERAL  REMARKS  ON  PATHOLOGY. 

examination  should  always  be  made  within  the  next  few 
days.  If  large  crusts  have  formed  by  secondary  exuda- 
tion of  fibrin,  they  should  be  loosened  with  liquid  va.selin. 
Deodorized  iodoform  or  nosophen  makes  a  good  protec- 
tive powder  for  cauterization  wounds  and  other  wounded 
surfaces. 

Electrolysis  is  used  chiefly  for  the  purpose  of  reducing 
the  size  of  malignant  tumors  which  evince  a  great  ten- 
dency to  bleed.  A  fine  double  platinum  needle  is  used, 
and  after  its  insertion  a  current  of  20  to  30  milliamperes 
is  gradually  turned  on.  It  may  be  allowed  to  act  for 
from  three  to  twenty  minutes.  The  actual  cautery  should 
be  used  only  when  the  interior  of  the  nose  has  been 
widely  laid  open  in  an  operation ;  under  such  circum- 
stances it  is  to  be  preferred  to  the  more  inconvenient  and 
less  radical  galvanocautery. 

Tumors  are  removed  with  a  cold  snare  or  the  galvano- 
cautery snare.  The  best  material  for  use  in  the  cold 
snare,  I  consider,  is  soft,  thin  brass  wire  ;  for  the  galvano- 
cautery snare  I  prefer  platinum.  [Iridoplatinum  wire 
is  preferable  for  this  purpose.  The  addition  of  the  irid- 
ium increases  the  stiffness  of  the  wire  without  interfering 
with  its  electric  properties. — Ed.]  The  guides  in  the 
cold  snare  must  be  completely  open  in  front,  not  held 
together  with  a  cross-piece,  so  that  the  snare  may  be  com- 
pletely drawn  into  the  tubes,  and  thus  cut  through  the 
entire  tumor-mass.  Soft  tumors  with  inaccessible  ped- 
icles are  difficult  to  seize  with  the  snare,  and  are  much 
more  readily  removed  with  the  forceps.  The  instrument 
to  be  used  is  not  the  old  style  of  coarse  dressing  forceps, 
which  was  introduced  without  the  aid  of  the  eye  and 
seized  tissue  at  random,  but  the  modern  bone-forceps, 
delicate  yet  strong,  which  is  introduced  under  guid- 
ance of  the  eye,  and  enables  the  operator  to  seize  a  frag- 
ment of  soft  tissue  without  cutting,  and  to  hold  it  fast 
until  it  can  be  removed  by  avulsion  or  torsion. 

This  procedure  is  to  be  preferred  to  a  clean  cut, 
because  in  the  so-called  polypi,  which  are  usually  sub- 


TREATMENT. 


49 


jected  to  tliis  treatment,  radical  removal  of  the  perios- 
teum, or  even  of  the  bone  to  which  the  polyp  is  attached, 


Fig.  10.— Scissors. 


is  the  only  means  of  preventing  recurrence.     The  pro- 
cedure does  not  produce  any  more  pain  or  hemorrhage 


50  GENERAL  REMARKS  ON  PATHOLOGY. 

than  follows  the  use  of  the  snare.  The  same  forceps  is 
used  to  remove  diseased  or  obstructing  portions  of  bone, 
the  instrument  making  a  clean  cut.  Scissors  of  similar 
shape,  also  introduced  under  the  guidance  of  the  eye 
(Fig.  10),  are  indispensable  in  dividing  adhesions,  re- 
moving shreds  of  tissue,  and  other  like  minor  operations. 

A  typical  operation  employed  to  secure  more  room  in 
the  nose,  and  not  infrequently  indispensable  in  opening 
up  the  small  system  of  accessory  cavities,  consists  in 
removal  of  the  middle  turbinate  or  of  its  anterior  half, 
and  should  be  mentioned  at  this  point.  In  the  illustra- 
tions (Figs.  11  and  12)  the  instruments,  for  purposes  of 
clearness,  are  drawn  in  a  position  more  horizontal  than 
that  really  occupied.  In  actual  practice  the  position  of 
the  external  nose  interferes  with  an  absolutely  horizontal 
position  ;  the  instrument  must,  therefore,  be  introduced 
more  from  below  upward.  The  two  jaws  of  the  forceps, 
as  shown  in  the  illustration,  are  applied  to  the  base  of  the 
anterior  extremity  of  the  turbinate,  which  is  cut  through 
by  rotating  the  instrument  on  its  longitudinal  axis.  The 
part  is  thus  prepared  for  the  snare,  which  is  then  imme- 
diately applied.  Either  the  cold  or  the  hot  snare  may 
be  used.  If  everything  goes  well,  the  hemorrhage  ceases 
at  once. 

For  scraping  away  granulations,  removing  thin  plates 
of  bone,  or  new  growths  situated  in  deep  recesses  of  the 
nose,  the  sharp  curet  (Fig.  13)  is  the  best  instrument ;  it 
should  always  be  used  under  the  guidance  of  the  eye. 
Most  operations  confined  to  the  interior  of  the  nose  can 
be  completed  without  resection,  but  in  the  presence  of 
malignant  tumors,  tuberculosis,  and  similar  conditions  it 
may  be  impossible  to  do  a  thorough  operation  because  the 
neoplasm  extends  far  beyond  the  visible  regions  of  the 
member.  In  such  cases  the  nose  must  be  laid  open.  In 
the  treatment  of  processes  confined  to  the  nasal  fossae  and 
more  or  less  accessible,  the  typical  Langenbeck  operation 
for  temporary  resection  of  the  nasal  bone  will,  as  a  rule, 
sii£Sce.     Bardenheuer's  operation  for  laying  open  the  face 


TREA  TMENT. 


51 


IS  indicated  only  in  exceptional  cases.  For  the  purpose 
of  exposing  conditions  localized  in  the  anterior  portion 
of  the  septum  and  on  the  floor  of  the  nose  I  have  re- 


Fio.  11. 


Fig.  12. 
Figs.  11, 12.— About  three-fifths  natural  size. 

peatedly  employed  the  following  typical  procedure  :  An 
incision  is  made  at  a  distance  of  ^  cm.  from  the  septum 
through  the  cartilaginous  portion,  upward  as  far  as  the  nasal 
bone,  and  then  along  the  apertura  pyriformis.     The  two 


52 


GENERAL  REMARKS  ON  PATHOLOGY. 


edges  are  then  clamped  with  Pean's  forceps,  and  a  com- 
pletely bloodless  operative  field,  every  portion  of  which  can 
readily  be  seen,  is  obtained.  The  tumor  itself,  and  the 
portion  of  the  septum  or  of  the  nose  to  which  it  is  attached, 
may  then  be  removed  with  the  actual  cautery,  again 
without  producing  hemorrhage. 

In  conclusion,  I  must  not  neglect  to  call  attention  to  a 


< z.  ..„::: 35, 

Fig.  13.— Curets,  actual  size ;  handles  about  one-half  actual  size. 

few  practical  points  in  nasal  operations.  When  oper- 
ating in  the  nose,  we  should  strive  to  eifect  the  following 
results : 

1.  The  removal  of  obstacles  to  respiration. 

2.  The  establishment  of  free  drainage. 

3.  Free  exposure  of  the  orifices  of  diseased  accessory 
cavities. 

4.  Removal  of  secondary  changes  which  tend  to  keep 


TREATMENT.  53 

up  the  original  or  a  similar  morbid  process  even  after  re- 
moval of  the  primary  cause. 

5.  Radical  removal  of  malignant  tumors  or  infectious 
processes. 

To  accomplish  these  objects  and  avoid  postoperative 
accidents  the  following  precautions  are  indispensable  : 

1.  Rapidity  combined  with  the  highest  possible  degree 
of  thoroughness. 

2.  The  establishment,  at  the  first  sitting,  of  perfect 
ventilation  on  the  side  subjected  to  treatment. 

3.  Cleanliness  in  operating  and  care  to  avoid  leaving 
shreds  of  tissue  or  other  matters  behind. 

The  use  of  antiseptics  of  any  kind  is  absolutely  un- 
necessary. The  introduction  of  infectious  materials  is  to 
be  avoided  by  keeping  the  hands  scrupulously  clean  and 
using  none  but  sterilized  instruments  and  dressings.  In 
operations  per  vias  naturnles  general  anesthesia  is  unneces- 
sary, except  in  children. 


SPECIAL  PATHOLOGY   AND    TREATMENT. 


Of  all  the  organs  in  the  body,  the  mouth  and  the 
throat  are  most  exposed  to  injuries  from  without.  Their 
anatomic  position  brings  them  into  contact  with  all  the 
ingredients  of  the  ingested  food  and  of  the  respired  air, 
and  their  function  of  initiating  the  process  of  digestion 
makes  it  impossible  for  them  to  avoid  these  injuries. 
Hence  it  is  readily  understood  that  this  region  often 
becomes  the  site  of  an  independent  traumatic  or  infec- 
tious disease,  and,  on  the  other  hand,  presents  the  initial 
stage  or  a  concomitant  condition  in  the  general  infectious 
diseases  which  select  this  region  as  their  point  of  attack. 

The  first  group  includes  typical  localized  and  extensive 
idiopathic  diseases,  which  derive  their  peculiar  character 
from  the  anatomic  alterations  on  which  they  are  based. 
The  second  group  embraces  more  extensive  symptomatic 
affections  of  a  mixed  character.  We  are  accordingly  justi- 
fied in  taking  account  of  this  natural  difference  in  de- 
scribing the  special  pathology. 

INFLAMMATIONS 

This  is  the  commonest  manifestation  of  disease.  We 
will  first  discuss  the  acute  forms.  Among  the  milder, 
more  superficial  varieties,  simple  catarrh  is  the  most  fre- 
quent. 

SIMPLE   ACUTE   CATARRH. 

Simple  acute  catarrh  of  the  mouth  almost  always  repre- 
sents a  mere  concomitant  symptom  of  a  neighboring  in- 
flammation, or  it  is  the  result  of  direct  injury,  such  as  the 
54 


SUPERFICIAL  INFLAMMATIONS.  55 

ingestion  of  irritating  food,  a  dental  operation,  excessive 
smoking,  and  the  like.  On  the  other  hand,  simple  in- 
flammation of  the  pharynx,  like  acute  coryza, — the  two 
being  usually  associated, — is,  in  the  majority  of  cases,  due 
to  infection  from  catching  cold. 

The  mucous  membrane  presents  varying  degrees  of 
redness.  In  the  mouth  it  is  often  slightly  clouded  by 
swelling  of  the  epithelium ;  in  the  nose  the  picture  is 
complicated  and  characterized  by  the  hyperemia  of  the 
erectile  tissue,  which  is  often  very  great. 

SUPERFIQAL   FORMS. 

In  the  mouth  the  epithelium  is  constantly  maltreated 
by  the  movements  of  the  inuscles  and  by  the  food,  and  is 
accordingly  abraded,  especially  between  the  folds  of  the 
mucous  membrane :  superficial  abrasions  are  produced 
(Plate  3,  Fig.  1).  Secretion  is  at  first  diminished,  and 
this  produces  a  feeling  of  dryness,  which  is  aggravated  by 
the  hyperemia  and  heat  of  the  mucous  membrane.  In  the 
mouth  this  feeling  manifests  itself  as  a  bad  ("  pasty ") 
taste ;  in  the  throat,  as  a  feeling  of  intense  thirst ;  later 
the  secretion  may  be  augmented  to  an  excessive  degree. 
Salivation  and  nasal  discharge  in  coryza  occasionally 
assume  astonishing  proportions.  In  the  nose  the  secre- 
tion at  first  is  exclusively  serous,  being  derived  from  the 
serous  glands  of  the  olfactory  region.  The  mucous  glands 
of  the  turbinates  do  not  participate  in  the  process  until 
later  on,  when  they  are  compressed  by  the  hyperemia  of 
the  erectile  tissue.  The  secretion  then  becomes  thready, 
later  contains  greater  masses  of  mucus,  and  sometimes 
is  even  purulent.  The  presence  of  thick  purulent  lumps 
indicates  that  the  accessory  sinuses  are  involved.  This  is 
also  the  cause  of  severe  headache.  Moderate  headache 
may  be  produced  by  the  pressure  of  the  swollen  mucous 
membranes  on  the  nerve-endings,  but  the  severest  types 
are  observed  when  there  is  retention  of  the  secretions 
behind  the  swollen  tissues. 


56  SPECIAL  PATHOLOGY  AND  TREATMENT. 

Tlie  skin  of  the  upper  lip  often  becomes  irritated,  espe- 
cially in  cliildren  ;  and  a  mild  grade  of  eczema  may  de- 
velop. The  conjunctiva  is  always  involved  to  a  greater 
or  less  extent,  either  mechanically  by  stagnation  of  the 
lacrimal  fluid  or  as  a  result  of  infectious  irritation.  At 
the  end  of  a  week,  at  the  latest,  unless  the  healing  proc- 
ess is  disturbed  by  improper  mode  of  life  or  too  active 
treatment,  an  acute  inflammation  begins  to  subside  ;  sali- 
vation diminishes  ;  the  irritation  of  the  throat  disappears ; 
and  only  a  little  mucus  is  expectorated  at  long  intervals. 
Nasal  respiration  is  restored ;  the  secretion  becomes  more 
periodic  and  almost  exclusively  nmcous,  and  soon  ceases 
altogether.  If  the  infection  has  been  unusually  severe,  or 
the  anatomic  conditions  are  very  unfavorable,  inflamma- 
tion of  an  accessory  cavity  may  remain.  It  is  recognized 
by  persistent  pain,  and  especially  by  unilateral  hypersecre- 
tion. 

The  treatment  calls  for  immediate  prohibition  of  every 
form  of  indulgence  that  may  be  productive  of  irritation, 
such  as  smoking,  taking  snuff,  and  indulgence  in  alcohol. 
A  bland  diet  should  be  ordered;  active  diaphoretic  laxa- 
tive measures  employed ;  and  the  patient  should  be  told 
to  avoid,  as  much  as  possible,  sudden  changes  of  tempera- 
ture and  air  contaminated  by  admixture  of  dust  and  other 
injurious  matters.  Angina  is  agreeably  alleviated  by 
gargling  with  lukewarm  alum  water.  In  the  nose  the 
aspiration  of  salt  solution  is  grateful.  In  children  l)orio 
acid  ointment  must  be  ordered  for  the  upper  lip,  and  in 
nursing  infants  the  nutrition  requires  special  attention  (see 
p.  27).     Headache  is  relieved  by  means  of  an  ice-bag. 

In  regard  to  internal  remedies,  if  the  coryza  is  severe 
and  the  general  infectious  symptoms  and  the  headache 
appear  to  demand  treatment,  salipyrin  in  doses  of  1  gram 
(15  gr.)  may  be  given  two  or  three  times  a  day. 

If  the  local  symptoms  are  severe  and  persistent,  the 
middle  meatus  may  be  cocainized,  and  the  middle  turbi- 
nate cautiously  pushed  to  one  side  with  a  probe.  The 
temporary  removal  of  the  secretions  secured  in  this  way 


SUPERFICIAL  INFLAMMATIONS.  57 

is  often  followed  by  disappearance  of  the  swelling  and 
permanent  drainage.  Inflammations  of  accessory  sinuses 
remaining  after  the  attack  has  subsided  require  no  special 
treatment  unless  exceptionally  alarming  symptoms  make 
their  appearance  or  the  condition  persists  without  im- 
provement for  several  weeks  (see  p.  91).  As  a  rule,  they 
subside  of  their  own  accord  if  the  patient  takes  ordinary 
care  of  his  health. 

True  inflammation  of  the  middle  ear  rarely  occurs  as  a 
complication  in  ordinary  catarrh,  but  a  slight  hyperemia 
of  the  middle  ear  and  at  the  orifices  of  the  tubes,  with 
earache,  is  quite  often  observed. 

A  superficial  inflammation  never  goes  on  to  Ulcera- 
tion except  for  some  special  reason  or  under  certain  pecu- 
liar local  conditions.  Ulceration  of  the  frenulum  linguae 
may  be  produced  in  infants  by  chafing  against  prematurely 
sharp  incisors  ;  in  new-born  infants  suifering  from  sepsis, 
the  process  beginning  w'ith  infection  of  the  glands  of  Bar- 
tholin ;  in  older  children  suff'ering  from  whooping-cough, 
by  chafing  of  the  tongue  against  the  incisors  while  it  is 
protruded  during  a  paroxysm  of  cough.  During  the 
height  of  an  attack  of  oral  catarrh,  especially  when  it  is 
secondary  to  catarrh  of  the  nose  and  is  at  first  neg- 
lected, shallow  and  very  painful  ulcers  are  occasionally 
observed,  situated  preferably  on  the  edge  of  the  tongue. 
In  chlorotic  women  the  resistance  of  the  mucous  mem- 
branes is  lowered,  and  inflammatory  ulcers  of  this  character 
have  been  observed  to  recur  at  regular  intervals,  and 
have,  accordingly,  been  designated,  perhaps  with  good 
reason,  "  chronic  recurring  aphthae." 

One  of  the  more  common  severe  forms  of  oral  catarrh 
is  mercurial  ptyalism.  If  the  condition  is  neglected,  an 
extensive  or  even  gangrenous  ulceration  (Plate  3,  Fig.  2) 
may  result,  which,  however,  possesses  no  characteristic 
features.  The  salivation  is  a  consequence  and  not  a  pro- 
drome of  the  catarrh,  as  was  formerly  supposed.  A  pecu- 
liar form  of  oral  catarrh  is  the  so-called  "  benign  pharyn- 
geal ulcer,"  which  consists  of  a  shallow  ulceration,  occur- 


58  SPECIAL  PATHOLOGY  AND  TREATMENT. 

ring  almost  always  on  one  of  the  anterior  pillars  above 
the  tonsil,  and  productive  of  slight  discomfort.  It  sub- 
sides of  its  own  accord  in  ten  days  at  most.  Whether  in 
this  case,  as  in  Bednar's  aphthae,  certain  special  conditions 
are  present  that  enable  a  traumatic  cause  to  act  must  be 
left  undecided.  Bednar's  aphthae  are  unquestionably 
caused  by  the  practice  of  wiping  the  infant's  mouth  with 
a  cloth.  This  irritates  the  mucous  membrane  which  is 
stretched  over  the  pterygoid  processes,  and  leads  to  in- 
flammation and  finally  to  ulceration  (Plate  14,  Fig.  2). 

The  constant  maceration  to  which  this  region  is  sub- 
jected is  responsible  for  certain  differences  in  the  appear- 
ance of  ulcers.  From  whatever  cause  and  in  whatever 
structure  ulcers  in  the  oropharynx  may  have  been  pro- 
duced, they  eventually  always  become  covered  with  a  fibrin- 
ous exudate,  so  that  a  true  ulcerative  surface  is  rarely  seen. 
The  new  epithelium  grows  underneath  the  covering  of 
fibrin.  At  the  margin  of  the  tongue,  however,  and  at  the 
bridle,  the  floor  of  the  ulcer  sometimes  becomes  exposed 
by  the  constantly  repeated  injuries. 

The  treatment  varies  with  the  origin  of  the  ulcer.  In- 
cisors with  sharp  edges  must  be  filed  off;  wiping  the  in- 
fant's mouth  must  be  interdicted  altogether ;  attacks  of 
whooping-cough  must  be  suppressed  as  much  as  possible. 
The  quickest  way  to  remove  the  pain  from  an  open  ulcer 
is  by  a  single  application  of  the  solid  stick  of  silver  nitrate, 
combined  with  the  constant  use  of  an  astringent  mouth- 
wash (see  ]).  40).  Mercurial  ptyalism  calls  for  an  imme- 
diate withdrawal  of  mercury,  constant  washing  of  the 
mouth  with  a  1  per  cent,  solution  of  potassium  chlorate, 
and  dusting  of  the  deeper  ulcerations  with  iodoform.  If 
the  gums  are  greatly  infiltrated,  it  is  a  good  plan  to  paint 
them  daily  with  a  4  per  cent,  solution  of  silver  nitrate. 

An  exceedingly  common  disease  of  childhood  is  so- 
called  aphthous  stomatitis,  consisting  of  disseminated 
deposits  of  fibrin  in  the  necrotic  epithelium  overlying  the 
somewhat  infiltrated  submucosa.  They  appear  as  yellow- 
ish-white, slightly  elevated  patches,  varying  in  si^e  from 


EXUDATIVE  INFLAMMATIONS.  59 

the  head  of  a  pin  to  a  lentil,  and  surrounded  by  a  narrow 
inflanimat(.ry  border  (Plate  5,  Fig.  2).  They  come  away 
very  slowly,  so  that  epithelialization  occurs  at  the  margin 
before  the  center  of  the  patch  has  separated.  At  this 
point  the  process  recurs  again  and  again,  so  that  all  the 
various  stages  of  development  can  be  observed  at  the 
same  time.  General  symptoms,  such  as  a  feeling  of  in- 
fection and  fever,  may  be  present  in  moderate  degree 
from  the  very  outset,  and  may  vary  with  the  severity  of 
the  case.  The  discomfort  and  pain  may  be  considerable 
on  account  of  the  excessive  salivation.  Adults  are  rarely 
attacked  by  the  disease,  except  under  conditions  that 
favor  the  production  of  stomatitis,  and  therefore  facilitate 
infection,  such  as  menstruation,  pregnancy,  chlorosis, 
and  especially  the  acute  infectious  diseases.  Even  in  chil- 
dren the  disease  presupposes  some  debilitating  influence. 
Those  chiefly  attacked  are  the  "scrofulous,"  or  those 
whose  mucous  membrane  is  already  irritated  by  a  catarrh 
complicating  the  existing  rhinitis  ;  bottle-fed  infants  and 
children  suffering  or  recovering  from  one  of  the  acute 
exanthemata.  With  proper  care  of  the  mouth  the  disease 
subsides  of  its  own  accord,  but  recovery  should  be  has- 
tened as  much  as  possible,  especially  in  children,  on 
account  of  the  attendant  disturbance  of  nutrition.  The 
alkalis  are  the  most  useful  remedies ;  for  older  children 
a  boric-acid  mouth- wash  may  be  ordered.  In  infants  the 
parts  should  be  painted  with  the  following  solution  : 

Sodium  biborate,  5.0 

Syr.  flor.  rhoeados 

(poppy),  100.0 

The  deeper  layers  of  the  mucous  membrane  when  dis- 
eased present 

EXUDATIVE  INFLAMMATIONS. 

The  rarest  and   most  peculiar  form  of  this  group  is 
found  in  the  gonorrheal  infection  of  small  children. 


60  SPECIAL  PATHOLOGY  AND   TREATMENT. 

A  cellular  exudate  consisting  principally  of  pus  is  de- 
posited immediately  beneath  tiie  true  mucosa,  and,  when 
the  latter  comes  away,  appears  on  the  surface.  At  first 
the  deposits  are  flat,  of  a  yellowish-white  color,  and  quite 
extensive  ;  later  they  become  converted  into  yellow  mem- 
branes that  peel  off  and  leave  flat  yellow  ulcers  which 
subsequently  become  red  and  slightly  uneven,  but  rapidly 
renew  their  epithelium.  The  process  is,  on  the  whole, 
benign,  and  is  confined  to  the  palate  between  the  two 
points  where  Bednar's  aphthse  are  localized,  the  anterior 
portions  of  the  tongue,  not  including  the  edges,  and  the 
alveolar  margins. 

The  diagnosis  is  based  on  the  localization,  the  presence 
of  gonorrhea  in  the  mother,  or,  if  necessary,  on  bacterio- 
logic  examination.     No  special  treatment  is  necessary. 

Another  form  of  fibrinous  exudation,  equally  benign,  is 
occasionally  met  on  the  tonsils  in  the  form  of  benign 
fibrinous' angina  (see  Plate  8,  Fig.  2).  It  is  distin- 
guished from  true  diphtheria  by  the  fact  that  it  is  confined 
to  the  surface  of  the  tonsils,  while  diphtheria,  though  it 
is  apt  to  appear  first  in  the  tonsils,  later  invades  all  the 
structures  of  the  pharynx  and  covers  them  with  discrete 
or  coalescent  membranes  (Plate  8,  Fig.  3).  Tlie  patches 
are  thick,  moderately  raised  above  the  surrounding  level, 
and  present  a  dull  white  luster.  As  the  exudate  occupies 
the  submucosa,  it  cannot  be  removed  without  destroying 
tissue,  and  therefore  causing  hemorrhage ;  after  sponta- 
neous separation  raw  surfaces  remain  which  soon  become 
covered  with  epithelium  ;  rarely  and  almost  always  with 
a  fatal  result.  A  diphtheritic  deposit  extends  more  deeply 
and  becomes  gangrenous,  as  the  grayish-green  discolora- 
tion of  the  membrane  indicates. 

Diphtheria. — In  adults  this  is  frequently  confined 
to  the  central  portions  of  the  pharynx  ;  in  children  the 
process  may  extend  downward  to  the  larynx,  and  is  par- 
ticularly apt  to  invade  the  nasopharynx  and  the  nose. 
Laryngoscopy  is  practically  impossible,  and  the  laryngeal 
involvement  is  recognized  by  the  nasal   quality  of  the 


EXUDATIVE  INFLAMMATIONS.  61 

speech,  the  snoring,  and  the  early  paralysis  of  the  soft 
palate.  The  nose  is  found  to  be  filled  with  thick,  yellow- 
ish-white membranes.  In  the  rare  cases  in  which  the 
disease  appears  primarily  in  the  nose,  a  flat,  membranous 
deposit  is  observed  at  the  vestibule,  especially  at  the  ante- 
rior extremity  of  the  septum,  surrounded  by  an  inflamma- 
tory areola  (Plate  30,  Fig.  4).  Sometimes  the  disease  is 
altogether  confined  to  this  area,  probably  owing  to  trau- 
matic local  infection  produced  by  picking  and  bruising 
the  nose  with  the  finger  or  conveying  carriers  of  infec- 
tion with  the  handkerchief.  The  general  symptoms  are 
quite  insignificant,  and  the  clinical  picture  is  that  of  a 
"  fibrinous  rhinitis,"  which,  however,  on  bacteriologic 
examination,  is  almost  always  found  to  be  a  true  diph- 
theria. 

Either  the  general  symptoms  pointing  to  severe  infec- 
tion, such  as  continuous  high  fever,  great  depression,  and 
headache,  more  or  less  depressed  heart  action,  predomi- 
nate, or  the  local  symptoms — dysphagia,  sore  throat,  and 
nasal  obstruction — may  be  the  most  conspicuous.  The 
clinical  picture  may  be  greatly  modified  by  complications, 
which  are  exceedingly  frequent.  They  consist  of  inflam- 
mations of  the  ears  ;  inflammation  or  even  breaking  down 
of  the  lymph-glands  ;  bronchitis ;  pneumonia ;  renal  irri- 
tation going  on  to  hemorrhagic  nephritis  ;  erythematous, 
impetiginous,  and  papular  cutaneous  eruptions  ;  and  true 
cutaneous  diphtheria. 

The  prognosis  is  doubtful ;  spontaneous  recovery  may 
ensue  after  an  attack  so  slight  as  almost  to  escape  notice, 
or  the  disease  may  run  a  protracted  course,  marked  by  re- 
lapses, especially  in  the  nose,  or,  finally,  the  disease  may 
take  the  form  of  a  profound  infection,  with  rapid  cardiac 
collapse  or  extensive  and  destructive  local  phenomena. 

Treatment. — As  cases  that  are  quite  mild  at  the  outset 
may,  in  their  subsequent  course,  become  very  malignant 
as  the  result  of  mixed  infection,  we  should,  if  possible, 
abort  the  attack.  Antitoxin  must,  therefore,  be  admin- 
istered :   in  the   first   days   a   single   dose ;   if  the   case 


62  SPECIAL  PATHOLOGY  AND  TREATMENT. 

is  seen  later,  two  or  three  doses  of  Behring's  serum. 
The  local  treatment  of  the  larynx  is  discussed  in  another 
place.  Warm  aromatic  gargles  or  nasal  irrigations  with 
a  tepid  1  per  cent,  solution  of  lime-water  are  indi- 
cated to  hasten  the  detachment  of  the  membranes ;  a 
protective  ointment  should  be  applied  to  the  skin  of  the 
nose  and  lips.  These  measures  may  be  supplemented  by 
a  wet  throat  compress  and  the  administration  of  cathartics. 
The  action  of  the  heart  must  be  carefully  watched,  and, 
if  necessary,  injections  of  camphor  administered  without 
delay.  The  patients  must  avoid  overexertion,  and  not 
be  allowed  to  get  up  too  soon  or  to  interfere  with  the 
action  of  the  kidneys  by  indulging  in  alcohol  or  irritating 
food. 

The  process  does  not  always  end  with  the  subsidence 
of  the  fever  and  of  the  membrane  formation ;  in  fact,  it  is 
just  during  the  period  of  convalescence  that  severe  palsies 
occur.  These  consist  in  paralyses  of  the  soft  palate, 
causing  regurgitation  of  food  through  the  nose  ;  paralysis 
of  the  vocal  cords,  and  sometimes  complete  aphagia  from 
paralysis  of  the  esophagus ;  paralysis  of  accommodation, 
shown  by  a  sudden  inability  to  recognize  near  objects, 
and  paralysis  of  the  abducens,  indicated  by  the  develop- 
ment of  strabismus.  Even  the  diaphragm  and  the  ex- 
tremities may  be  involved,  and,  what  is  more  alarming 
than  anything  else,  the  cardiac  fibers  of  the  pneumogastric 
are  not  infrequently  attacked.  The  sensory  nerves  also 
are  involved,  particularly  the  superior  laryngeal,  paralysis 
of  which  leads  to  anesthesia  of  the  entrance  to  the  larynx 
and  subjects  the  patient  to  the  danger  of  aspirating  por- 
tions of  food,  with  secondary  inspiratory  pneumonia.  In 
some  cases  the  patient  may  have  to  be  fed  for  weeks  with 
a  stomach-tube,  and  during  all  this  time  he  must  remain 
in  the  dorsal  position  so  as  to  avoid  the  slightest  exertion. 
Injections  of  nitrate  of  strychnin,  0.005  gm.  (gr.  ^)  two 
or  three  times  a  day,  are  said  to  hasten  the  disappearance 
of  the  paralysis.  Atrophy  from  disuse  may  at  least  be 
guarded  against  by  means  of  systematic  faradization. 


INTERSTITIAL  INFLAMMATION.  63 

INTERSTITIAL   INFLAMMATION. 

This  can  readily  be  subdivided,  both  on  clinical  and  on 
anatomic  grounds,  into  two  varieties,  although  from  an 
etiologic  standpoint  they  are  caused  by  the  same  bac- 
teria— usually  the  streptococcus  pyogenes. 

[Erysipelas  affects  the  mucosa  and  upper  layers  of  the 
submucosa.  It  is  characterized  by  extensive  but  sharply 
defined  redness  and  intense  elastic  swelling.  If  the  infec- 
tion has  been  very  severe,  blebs  may  be  formed  on  the 
mucosa,  but  suppuration  never  takes  place,  as  the  extrava- 
sation consists  entirely  of  serum  and  contains  very  few 
cells.  The  fever  is  quite  characteristic  ;  it  is  of  an  inter- 
mittent type,  corresponding  to  the  way  in  which  the  in- 
flammation spreads,  which  is  paroxysmal  rather  than  pro- 
gressive. Recurrences  are  common  in  the  same  individual, 
and  as  long  as  the  conditions  are  favorable  for  an  invasion, 
persist.  The  disease  preferably  begins  in  some  insignifi- 
cant abrasion  of  the  surface,  and  is  probably  propagated 
more  by  fission  fungi  already  residing  in  the  body  than 
by  freshly  imported  germs.  Accordingly,  we  observe 
that  erysipelas  preferably  begins  at  the  vestibule  of  the 
nose,  where  fissures,  abrasions,  and  especially  acne  pus- 
tules, which  commonly  accompany  chronic  inflammation 
of  the  interior  of  the  nose,  afford  ready  entrance  to  the 
bacteria  contained  in  the  secretion.  In  like  manner, 
although  much  more  rarely,  erysipelas  may  develop  in  the 
tonsils  or  at  the  pillars  of  the  fauces,  in  the  lacunae,  and 
supratonsillar  recess,  which  often  contain  infectious  mate- 
rial, and  where  abrasions  of  the  mucous  membrane  are  not 
uncommon.  It  is  extremely  rare  for  erysipelas  to  begin 
on  the  lips  or  the  mucous  membrane  of  the  mouth,  in 
spite  of  the  frequent  presence  of  fissures  at  the  angle  of 
the  mouth,  particularly  in  children.  If  these  structures 
are  attacked,  it  is  practically  always  owing  to  extension 
of  the  infectious  process. 

Erysipelas,  as  a  rule,  prefers  the  skin  to  mucous  mem- 
brane, and  nasal  erysipelas  extends  ten  or  even  a  hundred 


64  SPECIAL  PATHOLOGY  AND   TREATMENT. 

times  as  frequently  over  the  external  nose,  the  lips,  and 
the  face,  as  into  the  interior  of  the  nose,  whence  the 
disease  has  been  named  facial  erysipelas,  without  any 
regard  to  its  origin.  In  the  nose  the  process  fails  to  find 
a  favorable  field  for  the  development  of  its  activity ;  the 
mucous  membrane  is  everywhere  intimately  adherent  to 
the  periosteum  or  to  the  submucosa,  and  this  explains 
why  pharyngeal  erysipelas  sometimes  appears  to  follow 
directly  upon  erysipelas  of  the  face,  because  the  nasal 
affection  which  has  intervened  has  run  its  course  without 
leaving  a  trace. 

In  feci,  the  appearances  in  the  nose  are  anything  but 
striking ;  the  swelling  of  the  mucous  membrane  cover- 
ing the  turbinates  closely  resembles  that  of  an  ordinary 
catarrh.  It  is  only  at  the  septum  that  we  see  the  tense, 
glistening,  broad,  red  swelling  which  may  even  go  on  to 
vesicle  formation. 

The  nasopharyngeal  space  may  apparently  become  the 
primary  seat  of  erysipelas,  although  it  is  more  likely  that 
the  disease  was  present  in  a  latent  form  in  the  nose  and 
that  infection  originally  took  place  through  the  nostrils. 
Primary  nasopharyngeal  erysipelas  is,  however,  not  im- 
possible. 

The  mucous  membrane  in  erysipelas  is  of  a  dark-red 
color,  and,  owing  to  its  extreme  tension,  presents  a  dim 
luster.  The  boundary-line  between  diseased  and  healthy 
portions  is  sharply  defined  (Plate  9,  Fig.  2),  the  less  adhe- 
rent portions  (uvula)  become  greatly  deformed  by  reason 
of  the  edema,  so  that  intense  dysphagia  and  dyspnea  may 
develop  even  without  laryngeal  involvement.  In  the 
nasopharynx  erysipelas  hardly  ever  occurs  independently 
without  participation  on  the  part  of  the  soft  palate,  and  is, 
therefore,  difficult  to  detect  by  inspection.  It  may  occa- 
sionally attack  the  accessory  sinuses  of  the  nose,  and 
autopsies  have  shown  that  here  the  raucous  membrane 
also  becomes  covered  with  large  blebs,  which  may  rup- 
ture and  discharge  a  serous  effusion. 

The  constitutional  symptoms  usually  set  in  suddenly 


INTERSTITIAL  INFLAMMATION.  65 

and  are  violent  from  the  outset.  Fever,  delirium,  and 
great  prostration  are  not  uncommonly  observed.  They 
disappear  and  reappear  with  the  variations  in  the  tempe- 
rature, and,  if  the  progress  of  the  disease  is  arrested,  may 
subside  and  the  patient  may  feel  relatively  comfortable 
before  the  local  process  is  terminated.  The  heart  may 
show  the  effects  of  the  intoxication  and  occasionally  of 
metastasis  in  the  form  of  endo-  and  pericarditis. 

The  inflammation,  which,  on  the  whole,  is  benign,  may 
become  serious  when  it  extends  to  the  larynx  and  gives 
rise  to  symptoms  of  suffocation,  or,  as  occasionally  hap- 
pens, when  it  reaches  the  meninges  by  way  of  the  lymph- 
channels.  In  this  way  a  "  latent  meningitis,"  which  is 
rarely  diagnosticated,  develops.  Sequela?  are  rare.  Per- 
manent injuries  may  occasionally  remain  behind  in  the 
pneumatic  cavities,  owing  to  some  peculiar  anatomic  con- 
ditions. 

Expectant  treatment  is  all  that  is  required,  due  atten- 
tion being  given  to  supportive  measures  and  abundant 
feeding.  The  strict  supervision  of  the  heart,  which  some- 
times shows  sudden  depression  and  requires  stimulation, 
is  not  to  be  neglected.  The  treatment  should  not  end 
with  the  subsidence  of  the  acute  attack.  The  return  of 
the  infection  must  be  guarded  against  after  complete  con- 
valescence by  instituting  a  diligent  search  for  the  causal 
factors  which  have  been  described. 

When  the  deep  layers  of  the  submucosa  and  of  the 
intermuscular  connective  tissue  are  attacked  by  inflamma- 
tion, the  process  takes  on  the  character  of  phlegmon, 
with  abundant  cellular  infiltration,  which  terminates  in 
suppuration.  The  surrounding  tissues  may  present  cir- 
cumscribed areas  of  edema  due  to  compression  of  the 
veins,  but  the  characteristic  features  of  the  process  consist 
in  relatively  slight  alteration  of  the  surface,  with  diffuse 
swelling  of  stony  hardness  in  the  deeper  tissues.  Very 
slowly  the  infiltration  may  make  its  way  to  the  mucous 
or  cutaneous  surface,  a  discolored  spot  is  former],  the 
abscess  points,  and  eventually  ruptures.     TJie   tempera- 


66  SPECIAL  PATHOLOGY  AND  TREATMENT. 

ture  presents  the  type  of  purulent  fever  with  slight  re- 
missions, and  does  not  subside  until  the  pus  has  been 
evacuated,  either  spontaneously  or  by  operative  means. 
The  constitutional  symptoms,  which  are  those  of  a  general 
intoxication  with  cardiac  weakness,  generally  make  their 
appearance  gradually  and  may  assume  alarming  propor- 
tions until  the  abscess  ruptures,  while  the  local  sym])toms, 
consisting  in  throbbing  pain  and  a  feeling  of  tension,  are 
specially  noticed  during  the  early  stages.  In  milder  cases 
they  may  be  exceedingly  severe ;  in  severer  cases,  on  the 
other  hand,  they  may  be  entirely  masked  by  the  general 
hebetude.  When  the  infection  is  unusually  virulent  and 
is  combined  with  a  deep  infiltration,  exerting  pressure 
on  the  nerves  and  vessels  of  the  neck,  the  absorption  of 
toxins,  owing  to  the  continuous  high  pressure,  may  go 
on  rapidly  and  uninterruptedly  and  bring  on  the  severe 
general  disease  which,  under  the  very  appropriate  name 
"  acute  infectious  phlegmon,"  has  usurped  a  special  place 
in  the  literature  and  which  sometimes  terminates  fatally 
in  a  most  unexpected  manner. 

The  clinical  appearances  in  phlegmon  vary  greatly  ac- 
cording to  the  localization.  The  process  is  always  strictly 
confined  to  the  affected  point,  from  which  the  inflamma- 
tion spreads  by  continuity,  and  through  which  the  pus 
can  always  be  reached. 

From  the  entrance  to  the  nose  the  inflamma- 
tory process  may  extend  either  to  the  upper  portion  of 
the  upper  lip  or  to  the  external  nose.  In  both  these 
places  the  infection  may  begin,  although  rarely,  from  the 
sebaceous  glands  of  the  vibrissse.  Inflammations  in  the 
floor  of  the  nose  and  on  the  septum  are  derived  from 
the  roots  of  the  incisors  ;  they  develop  rather  slowly,  and 
are  apt  in  this  area  to  be  mistaken  for  specific  inflanmia- 
tions.  The  liability  to  error  is  even  greater  in  the  rare 
purulent  infiltrations  that  occur  in  the  hard  palate  and 
in  the  form  of  tongue  abscesses.  Minute  inquiry  into  the 
history  and  an  examination  of  the  entire  body  should  in 
most  cases  guard  against  this  error.   Tongue  abscesses, 


INTERSTITIAL  INFLAMMATION.  67 

especially  when  deeply  situated,  develop  very  slowly  and 
may  give  rise  to  alarming  symptoms,  owing  to  edema 
in  the  adjacent  structures  of  the  pharynx  and  larynx. 

The  most  dangerous  form  of  phlegmon  is  that  which 
occurs  on  the  floor  of  the  mouth,  in  the  angle  of  the 
lower  jaw,  between  the  genioglossus  and  mylohyoid  mus- 
cles. It  is  generally  known  under  the  name  of  I/Udwig'S 
angina,  a  term  that  is  often  indiscriminately  applied  to 
a  great  variety  of  suppurative  processes  in  the  neck.  In 
this  condition  the  pus  is  confined  in  the  depths  of  the 
tissue.  There  is  an  enormous,  board-like  swelling  of  the 
structures  of  the  neck,  forcing  the  head  upward  and  for- 
ward like  a  stiff  cravat,  and  very  often  leading  to  sudden 
asphyxia.  In  extreme  cases  the  patient's  life  can  be 
saved  only  by  early  and  deep  incision  in  the  median  line 
between  the  fibers  of  the  cervical  fascia  and  the  genio- 
glossus muscle,  and  penetrating  still  more  deeply  into  the 
lateral  tissues  of  the  neck  with  a  blunt  instrument  until 
the  pus  is  liberated.  In  addition  there  may  be  a  more 
circumscribed  and  less  dangerous  infiltration  around  the 
sublingual  gland,  which,  after  it  has  been  freely  exposed, 
may  apparently  subside  without  suppuration,  but  in  any 
case,  no  matter  how  slight  the  symptoms  may  be,  an  in- 
filtration in  this  region  calls  for  the  greatest  care  and 
watchfulness,  for  in  this  form,  as  well  as  in  the  deep  cer- 
vical phlegmon,  which  is  quite  similar  to  it,  death  from 
edema  of  the  larynx  or  sudden  heart  failure  may  occur 
unexpectedly. 

Fortunately,  these  deep-seated  suppurative  processes  are 
quite  rare,  and  in  this  respect  differ  widely  from  pharyn- 
geal abscesses.  The  commonest  form  is  the  typical 
SUpratonsillar  phlegmon  or  abscess.  It  originates 
in  the  supratonsillar  fossa,  which  is  situated  between  the 
arches  of  the  palate,  and,  on  account  of  its  depth,  pre- 
sents great  facilities  to  the  entrance  of  infection.  The 
connective  tissue  between  the  tops  of  the  arches,  as  well 
as  the  intramural  connective  tissue  of  the  soft  palate, 
becomes  densely  infiltrated.     Accordingly,  the  swelling 


68  SPECIAL  PATHOLOGY  AND   TREATMENT. 

causes  the  anterior  pillar  of  the  fauces  to  bulge  forward 
and  completely  conceal  the  tonsil  itself,  which  is  only 
slightly  inflamed.  The  abscess  gradually  points  outward 
and  upward  (Plate  9,  Fig.  1).  Owing  to  the  extreme 
tension  of  the  fascia  of  the  internal  pterygoid  muscle,  it 
forms  the  outer  boundary  of  the  abscess ;  there  is  great 
interference  with  the  movement  of  the  jaws,  so  that  it  is 
often  impossible  to  insert  even  a  spatula  between  the 
teeth.  The  inflammation  rarely  spreads  to  adjacent  re- 
gions, but  the  rapid  absorption  of  toxins  due  to  the  great 
tension  of  the  tissues,  the  severe  pain,  and  total  dysphagia 
rapidly  undermine  the  individual's  strength.  For  this 
reason  the  pus  should  be  liberated  as  soon  as  the  condi- 
tion is  recognized.  If  incision  is  delayed  imtil  fluctuation 
and  pointing  beneath  the  mucous  membrane  of  the  palate 
make  their  appearance,  spontaneous  rupture  will  be  very 
little,  if  at  all,  anticipated.  The  pus  can  be  reached  by 
following  its  own  path  with  a  bent  probe  introduced 
through  the  supratonsillar  fossa  outward  and  upward. 
If  a  good  deal  of  pus  has  already  been  formed,  it  will  at 
once  follow  the  withdrawal  of  the  instrument ;  but  if  pus- 
formation  has  only  begun,  the  pus  may  be  obscured  by 
the  slight  hemorrhage  which  follows  the  introduction  of 
the  probe,  although  the  morbid  process  is  at  once  arrested, 
as  the  subsequent  course  will  show.  Sometimes  the  pus 
discharges  in  the  course  of  an  hour  or  two,  having  over- 
come the  slight  remaining  obstruction.  In  any  case  the 
insignificant  operation  is  productive  of  the  greatest  bene- 
fit, as  it  at  once  arrests  the  inflammatory  process.  Its 
great  usefulness  and  the  complete  absence  of  danger,  as 
compared  with  incision,  should  win  for  this  procedure  a 
place  in  the  routine  practice  of  every  physician. 

Abscesses  of  the  adenoid  tissue  will  be  discussed  in 
another  place  (see  p.  141). 

Peritonsillar  suppurations  are  due  to  tonsillar 
abscesses,  infection  by  foreign  bodies,  and  especially  to 
carious  teeth.  The  "  intermaxillary  fold  "  coimecting  the 
upper  and  lower  maxillsg  in  the  posterior  portion  of  the 


GANGRENE.  69 

mouth  is  occasionally  the  seat  of  a  characteristic  infiltra- 
tion ;  sometimes  deep  cavities  are  formed  in  this  region 
and  extend  toward  the  lower  jaw,  or  the  swelling  is 
not  observed  until  it  reaches  the  lower  jaw,  no  swelling 
being  visible  at  the  original  site,  because  it  has  already 
subsided.  A  lymphadenitic  abscess  may,  of  course,  also 
develop  in  this  region,  and  may  even  appear  to  be  pri- 
mary, hence  a  diagnosis  of  this  condition  in  the  neck 
should  always  be  made  witii  great  caution. 

In  addition  to  the  forms  of  phlegmon  described,  innu- 
merable variations  are  possible  and  could  not  be  exhausted 
by  the  most  far-reaching  description. 

It  is  well  known  that  the  nasopharynx  also  may  be- 
come involved.  Clinically  it  is  impossible  to  distinguish 
between  a  simple  phlegmon  in  Rosenmiiller's  fossa  and  the 
interstitial  inflammations  of  the  pharyngeal  tonsil  dis- 
cussed elsewhere  (see  p.  142).  All  that  can  be  said  is 
that  the  dreaded  retropharyngeal  abscesses  preferably 
begin  in  this  region. 

The  treatment,  as  has  already  been  indicated,  consists 
in  evacuating  the  pus  by  surgical  means  as  early  as  pos- 
sible. In  addition,  the  benefit  to  be  derived  from  wet 
compresses  and  gargles  used  as  hot  as  possible  need  hardly 
be  mentioned.  Absolute  rest  in  bed,  even  during  the 
first  days  of  convalescence,  should  be  enjoined,  and  the  in- 
toxication combated  by  giving  the  patient  plenty  of  alco- 
hol, as  this  has  been  found  by  experience  to  be  the  best 
means  of  counteracting  the  infection. 

In  this  condition  also  recurrence  must  be  guarded 
against  later  on  by  removing  any  possible  cause  for 
another  attack,  such  as  carious  teeth,  a  suppurative  rhi- 
nitis, necrotic  plugs  in  the  tonsils,  and  other  like  condi- 
tions. 

GANGRENE. 

The  only  form  of  inflammation  that  extends  even  more 
deeply  than  those  that  have  been  described  is  gangrene^ 
which  in  the  region  of  the  mucous  membranes  with  which 


70  SPECIAL  PATHOLOGY  AND  TREATMENT. 

we  are  now  occupied  occurs  under  the  name  of  noma  or 
"  water-cancer."  It  is  a  peculiar  disease,  which,  fortu- 
nately, rarely  occurs  at  the  present  time.  It  affects 
principally  children  between  eight  and  twelve,  and  un- 
doubtedly depends  on  a  severe  specific  infection.  In 
typical  cases  it  begins  in  front  of  the  caruncle  of  the  duct 
of  Steno  as  a  bluish-red  discoloration,  and  spreads  rapidly 
to  the  mucous  membrane,  the  muscles,  and  periosteum, 
and  even  downward  to  the  bone  and  upward  to  the 
skin.  In  a  few  days  the  necrotic  tissue  separates  and  a 
broad  and  deep  defect  results.  Coma  and  delirium  make 
their  appearance  early,  and  death  usually  terminates  the 
horrible  drama  in  a  short  time.  Occasionally,  how- 
ever, the  absence  of  subjective  symptoms  is  in  marked 
contrast  to  the  frightful  local  disease.  In  very  rare  cases 
the  ulcerated  surface  clears  up,  the  remaining  tissue  then 
skins  over  quite  rapidly,  although  the  cheek  remains  fenes- 
trated, leaving  the  interior  of  the  mouth  completely  ex- 
posed. An  extensive  plastic  operation  becomes  necessary, 
and  the  patient  has  to  be  fed  artificially  for  a  long  time 
until  the  wound  closes. 

The  treatment  is  confined  to  keeping  up  the  patient's 
strength.  The  frightful  odor  from  the  decomposing 
masses  of  tissue  may  be  mitigated  by  dusting  the  parts 
with  freshly  roasted  and  ground  coffee. 

The  necrosis  of  soft  parts  and  of  bones  that  occasionally 
occurs  after  severe  suppurations  in  the  accessory  sinuses 
is  discussed  on  page  98. 

SYMPTOMATIC   COMBINED  FORMS. 

THE  ACUTE  EXANTHEMATA. 

The  acute  exanthemata  never  run  their  course  without 
some  effect  on  the  mucous  membranes.  The  coryza  that 
occurs  during  the  incubation  period  of  measles  is  well 
known.  If  this  occurs  in  connection  with  conjunctivitis 
in  children  who  have  never  had  the  disease,  the  "spots" 
may  be  confidently  expected.    The  eruption  declares  itself 


THE  ACUTE  EXANTHEMATA.  71 

in  the  pharynx  on  the  very  first  day  of  the  fever,  in  the 
form  of  erytliematous  macules  at  the  junction  between  the 
hard  and  soft  palates.  The  center  of  the  macules  is 
occupied  by  minute  whitish,  slightly  prominent  vesicles. 
[In  1896  Koplik,  of  New  York,  called  attention  to  the 
early  appearance  on  the  buccal  mucosa,  in  measles,  of  what 
are  known  as  "  Koplik's  spots."  They  appear  from  one 
to  five  days  before  the  rash  typical  of  the  disease.  They 
are  to  be  looked  for  by  everting  the  lips  and  cheeks  under 
direct  daylight.  They  consist  of  small,  irregular  spots, 
bright  red,  with  a  minute,  bluish-white  speck  in  the  center. 
They  are  not  removed  by  any  smooth  instrument,  but  may 
be  picked  up  with  forceps.  They  are  made  up  of  diplo- 
cocci  and  epithelia,  and  measure  from  0.2  to  1  ram.  in  di- 
ameter. At  first  discrete,  they  may  later  coalesce. — Ed.] 
Coincidentally  with  the  appearance  of  the  cutaneous  erup- 
tion on  the  third  day  of  the  disease  the  efflorescence 
rapidly  spreads  to  the  entire  oral  mucous  membrane, 
except  the  tonsils  and  pillars  of  the  fauces,  which  continue 
to  present  diffuse  reddening,  as  at  the  beginning  of  the 
attack.  Occasionally  small  hemorrhages  take  place  into 
the  mucous  membrane.  This  diffuse  secondary  extension, 
however,  presents  a  distinctly  more  inflammatory  charac- 
ter. In  mre  cases  the  epithelium  desquamates,  and  ero- 
sions result. 

In  the  nose  and  nasopharynx  the  eruption  can  also  be 
recognized  on  the  greatly  swollen  mucous  membrane 
during  the  first  day  of  the  attack  if  solar  illumination 
is  employed.  The  nasal  obstruction  usually  persists  dur- 
ing the  fever,  and  adds  to  the  unpleasant  dryness  of 
the  oral  mucous  membrane,  which  may  be  so  extreme  as 
to  lead  to  the  formation  of  crusts  and  fissures  on  the 
tongue  and  lips.  There  is  a  profuse  mucopurulent  secre- 
tion both  from  the  nose  and  from  the  accessory  cavities ; 
in  rare  cases  the  secretion  may  even  take  on  the  charac- 
teristics of  a  fibrinous  exudate. 

Scarlet  fever  is  ushered  in  by  severe  angina,  which 
in  the  subsequent  course  of  the  disease,  probably  owing 


72  SPECIAL  PATHOLOGY  AND  TREATMENT. 

to  mixed  infection,  may  go  on  to  diphtheria.  Not  infre- 
quently abscesses  of  various  kinds  are  formed,  or  a  severe 
lymphadenitis  develops.  The  suppurative  process,  as 
usual,  preferably  attacks  the  adenoid  layer,  sometimes 
also  the  follicles  in  the  pillars  of  the  fauces  and  in  the 
soft  palate,  so  that  permanent  perforations  may  remain. 
These  perforations  may  be  distinguished  from  syphilitic 
defects  by  the  absence  of  scars  in  their  immediate  neigh- 
borhood. They  are  apt  to  be  diagnosed  erroneously  in 
later  life  as  "  congenital  "  conditions.  [Some  of  these 
openings  are  congenital,  doubtless  due  to  incomplete 
closure  of  branchial  clefts.  Moreover,  syphilitic  perfora- 
tions are  not  always  accompanied  by  scars  in  the  sur- 
rounding tissue. — Ed.]  We  also  speak  of  a  "scarlet- 
fever  tongue."  The  tongue  is  swollen  in  a  characteristic 
manner,  exceedingly  dry  and  intensely  red,  presenting 
great  prominence  of  the  papilla?,  so  that  the  surface  re- 
sembles that  of  a  strawberry.  Dryness  of  the  mouth  is 
also  a  prominent  feature,  as  the  nasal  mucous  membrane 
becomes  greatly  swollen,  thereby  occluding  the  nares, 
and  secretes  freely ;  in  fact,  it  very  frequently  becomes 
diphtheritic.  When  the  head  is  extensively  involved, 
the  punctiform  eruption  may  spread  to  the  mucous  mem- 
brane of  the  nose  and  nasopharynx.  The  accessory  cavi- 
ties are  also  quite  frequently  attacked.  Protracted  catarrh 
of  the  accessory  cavities  and  of  the  nasal  mucous  mem- 
brane, which  eventually  becomes  atrophic  (see  Ozena, 
p.  90),  is  frequently  a  sequel  of  scarlet  fever. 

The  eruption  of  rotheln  or  German  measles  is  seen 
only  in  the  mouth  ;  the  nose  escapes  altogether.  The 
secondary  stomatopharyngitis  characteristic  of  measles  is 
absent.  The  lesions  of  varicella  preferably  become 
localized  on  the  hard  palate,  very  rarely  in  the  nose. 
After  the  vesicles  rupture,  a  shallow  erosion  remains, 
which  rapidly  heals. 

In  small-pox  the  oropharynx  is  involved  as  regularly 
and  in  the  same  manner  as  the  skin  ;  the  lesions  here 
also   end   in   pustulation   and    scar-formation.      Typical 


STOMATITIS.  73 

pustules  are  also  formed  iu  the  nose,  especially  about  the 
vestibule.  Diphtheric  necrobiosis  occurs  both  here  and 
in  the  pharynx. 

All  these  diseases  have  one  sequel  in  common — namely, 
a  permanent  hyperplasia,  involving  especially  the 
piiaryngeal  portion  of  the  lymphatic  ring,  which  always 
shares,  as  a  whole,  in  the  inflammation  of  the  mucous 
membrane.  When  the  causes  of  adenoid  vegetations 
are  inquired  for,  the  acute  exanthemata  and  especially 
measles  will  almost  always  be  given  in  the  history. 
The  symptoms  usually  develop  soon  after  the  end  of 
convalescence. 

Local  treatment,  especially  of  the  nose,  is  particularly 
desirable  in  the  acute  eruptive  fevers.  Secondary  aural 
inflammations,  septic  processes,  or  at  least  permanent  in- 
flammations of  the  mucous  membranes  affected,  would  be 
much  more  frequently  prevented  if  the  infectious  material 
that  accumulates  in  such  large  quantities  in  the  nose  were 
removed,  and  nasal  respiration,  which  exerts  so  beneficial 
an  influence,  restored.  Some  form  of  spray  or  irrigation 
and  a  gargle  should  be  used  whenever  at  all  possible.  In 
very  small  children  and  in  stuporous  patients  much  good 
may  be  done  by  cleansing  the  floor  of  the  nose  at  frequent 
intervals,  using  a  probe  wound  with  a  thin  layer  of  cotton 
and  dipped  in  liquid  vaselin  (see  p.  46).  Astringent  and 
antiseptic  remedies  are  not  necessary,  and  are,  in  fact,  of 
no  use. 

STOMATITIS. 

The  disease  recently  identified  as  human  mouth  disease 
(since  it  is  hardly  permissible  to  speak  of  "claw  disease  " — 
foot  and  mouth  disease)  presents  some  similarity  to  the 
acute  exanthemata.  The  affection  has  been  aptly  termed 
epidemic  stomatitis.  After  severe  prodromal  symp- 
toms lasting  three  days,  and  consisting  in  chills  and  fever, 
with  headache,  abdominal  pain,  diarrhea,  and  sometimes 
vomiting,  the  temperature  falls,  the  bowels  become  ob- 
stinately constipated,  and  an  eruption  suggesting  measles 


74  SPECIAL  PATHOLOGY  AND   TREATMENT. 

appears  on  the  arms  and  thighs,  and,  rarely,  on  the 
trunk.  Sometimes  there  is  a  cliaraeteristic  eruption  of 
vesicles  filled  with  a  turbid  fluid  about  the  nails  of  the 
fingers  and  toes  and  around  the  mouth  and  nose,  sug- 
gesting the  foot  and  mouth  disease  of  cattle.  In  addi- 
tion, there  is  great  swelling,  with  livid  discoloration  of 
the  entire  oropharyngeal  mucous  membrane  and  profuse 
salivation.  Vesicles  similar  to  those  described  and  attain- 
ing sometimes  the  size  of  a  pea,  on  a  somewhat  swollen 
and  injected  base,  appear  scattered  over  the  mucous 
membrane.  They  soon  rupture  and  leave  a  shallow  ulcer, 
the  floor  of  which  is  covered  with  a  fibrinous  exudate. 
The  remaining  objective  symptoms  include  marked  swell- 
ing of  the  cervical  glands  and  of  the  liver.  The  spleen 
is  not  enlarged. 

The  outcome  is  not  always  favorable,  and  relapses  are 
not  uncommon.  Sometimes  the  inflammation  involves 
the  muscles  of  the  tongue  and  the  submucosa,  and  is  fol- 
lowed by  secondary  cicatricial  contraction. 

The  treatment  should  be  directed  chiefly  to  disinfection 
of  the  bowels,  as  the  infection  is  evidently  imported 
through  the  intestinal  tract  by  drinking  the  milk  of  dis- 
eased cows.  For  the  rest,  the  symptoms  must  be  met  as 
they  arise. 

INFLUENZA. 

Although  in  the  first  large  epidemics  of  influenza  in  onr 
generation  involvement  of  the  higher  mucous  membranes 
was  the  rule,  the  more  recent  epidemics  of  this  peculiar 
disease  have  often  run  their  course  unaccompanied  by  any 
kind  of  "catarrh,"  and  we  must,  therefore,  conclude  that 
the  catarrh  is  not  characteristic  and  is  merely  a  localiza- 
tion of  the  infection.  If  the  nose  is  attacked,  epistaxis 
is  frequent,  and  profuse  catarrh  always  results ;  and  it 
may  be  said  of  the  latter  that  it  is  never  unaccompanied 
by  disease  of  the  accessory  sinuses.  Already  existing 
catarrh  in  these  cavities  suffers  intense  exacerbation,  while 
recent  catarrhs  may  become  chronic.     The  extraordinary 


TYPHOID  FEVER.  75 

frequency  of  severe  disease  of  the  accessory  sinuses,  with 
suppuration  and  even  necrosis,  that  follows  an  epidemic 
of  "  nasal "  influenza  may  be  the  cause  of  serious  mis- 
takes in  regard  to  the  frequency  of  disease  of  the  accessory 
sinuses  in  general. 

The  subjective  symptoms,  vertigo,  stupor,  and  head- 
ache, are  particularly  frequent  and  remarkably  severe  in 
nasal  influenza,  although  these  symptoms  may  occur  in 
the  form  of  neuralgia  of  the  nasal  and  facial  branches  of 
the  trigeminal  nerve  without  any  catarrhal  rhinitis. 

Peculiar  features  of  influenza  sometimes  observed  with- 
out catarrh  are  cacosmia  and  parosmia,  conditions  that 
may  persist  for  some  time  after  recovery. 

If  the  pharynx  is  involved,  either  catarrhal  angina 
combined  with  edema,  or  infiltration  of  the  deep  muscular 
layers  with  dysphagia  and  severe  pain,  may  develop. 
Suppuration  of  the  follicles  about  the  pillars  and  in  the 
tonsils,  as  well  as  the  formation  of  phlegmons,  has  been 
reported. 

TYPHOID  FEVER. 

In  typhoid  fever  epistaxis  occurs  so  frequently  in  one- 
half  the  cases  toward  the  end  of  the  first  week  in  patients 
under  forty  years  of  age  that  the  symptom  is  regarded  as 
of  diagnostic  value.  The  hemorrhage  is  not,  as  was  for- 
merly believed,  due  to  diffuse  hyperemia  of  the  raucous 
membrane,  which  in  typhoid  fever  is  usually  very  dry, 
both  in  the  mouth  and  in  the  nose.  The  discharge,  which 
in  the  nose  is  often  purulent,  especially  if  it  originates  in 
the  sphenoid  sinus  or  in  one  of  the  other  accessory  sinuses 
that  are  frequently  involved,  tends  to  dry  up  and  form 
crusts  which  adhere  to  the  lips  and  to  the  nasal  septum. 
These  crusts  are  removed  by  scratching — many  patients 
are  always  seen  with  their  hands  to  their  noses;  the 
mucous  membrane,  the  nutrition  of  which  is  already 
impaired  bv  the  infective  process,  gives  way,  and  a  hem- 
orrhage from  the  "  locus  Kiesselbnchii "  results. 

In  the  oropharynx  diffuse  catarrh  with  tenacious,  dry, 


76  SPECIAL  PATHOLOGY  AND   TREATMENT. 

mucous  secretion  is  at  first  a  prominent  feature.  Some- 
times the  epitiielium  becomes  completely  desiccated  and 
desquamates  in  fine  saccules  —  the  angine  pultacee  of 
French  writers.  Not  so  very  rarely  abrasions  and  flat 
ulcers  covered  with  a  fibrinous  exudate  of  an  aphthous 
nature  are  formed,  especially  on  the  pillars  of  the  fauces 
and  on  the  soft  palate  (Plate  13,  Fig.  1),  or  ulcerations 
extending  down  to  the  muscular  layer  may  develop. 
These  lesions,  as  a  rule,  heal  readily  by  rapid  removal  of 
the  epithelium  and  leave  no  scars. 

The  peculiar  "  fuliginous  "  appearance  of  the  tongue  is 
familiar;  it  consists  of  a  heavy  coating,  with  dark-red 
discoloration  of  the  margin.  Care  of  the  mouth  and 
pharynx  are  doubly  important  in  typhoid  fever  on  account 
of  the  great  tendency  to  the  formation  of  decubital  sores 
in  the  mucous  membranes.  An  alkaline  mouth-wash 
should  be  used  at  short  intervals,  and  the  patient  made 
to  gargle  if  possible.  The  nose  should  be  painted  with 
liquid  vaselin  to  prevent  inspissation  of  the  secretions 
and  thus  guard  against  complications. 

HERPES. 

The  peculiar  general  infection  which  manifests  itself 
in  herpes  sometimes  attacks  the  mucous  membrane  of  the 
mouth  and  pharynx.  It  is  rarely  possible  to  observe  the 
first  stage — that  of  vesicle  formation — because  the  vesicles, 
owing  to  the  delicate  nature  of  their  epithelial  covering, 
rapidly  rupture  and  are  replaced  by  ulcers.  These  ulcers 
in  a  very  short  time  become  covered  with  a  delicate 
fibrinous  exudate  and  closely  simulate  aphthous  ulcers. 
It  is  very  probable  that  the  diagnosis  of  this  compara- 
tively common  affection  is  often  erroneously  made  in  cases 
of  herpes.  The  sudden  onset  of  the  disease  with  chills 
and  abrupt  rise  of  temperature,  tiie  general  feeling  of 
malaise,  the  acute  burning  local  pain,  and,  above  all,  the 
characteristic  grouping  of  the  lesions,  assure  the  diagnosis 
(Plate  13,  Fig.  2).      The  severity  of  the  pain   may  be 


SYPHILIS.  77 

alleviated  by  giving  antipyrin  or  phenacetin  internally ; 
locally  a  single  application  of  the  solid  stick  to  the  freshly 
formed  ulcers  has  a  very  good  effect. 


SYPHILIS. 

The  acute  inflammations  that  develop  in  the  wake  of 
syphilis  have  more  than  a  symptomatic  significance.  They 
usually  appear  in  the  secondary  stage,  either  shortly 
before  or  coincident  with  the  eruption,  and  are  rarely 
absent.  One  of  the  earliest,  and  a  rather  ambiguous 
sign,  is  a  diffuse  erythema.  Acute  coryza  in  infants,  even 
without  any  signs  of  syphilis  on  the  body,  is  undoubtedly 
to  be  regarded  as  syphilitic,  and  a  violent  catarrhal  red- 
dening at  the  entrance  to  the  pharynx,  lasting  over  eight 
days,  especially  when  it  occurs  in  young  adults  and  is 
accompanied  by  extreme  pain  without  any  apparent  rea- 
son, should  always  excite  a  suspicion  of  lues. 

Before  long  the  pathologic  appearances  become  unmis- 
takable, the  epithelium  appears  cloudy  and  macerated, 
the  mucous  membrane  becomes  slightly  raised  in  more  or 
less  extensive  areas,  and  the  characteristic  papule,  which 
at  first  is  distinguished  from  the  surrounding  tissue  by  its 
glistening  surface  and  later  becomes  converted  into  a 
thick,  white  or  yellowish-gray  wheal,  makes  its  appear- 
ance (Plate  10,  Fig.  2).  The  favorite  seat  of  the  papule 
is  the  entrance  to  the  pharynx  ;  it  is  also  observed  quite 
frequently  on  the  tongue,  where  it  must  be  carefully 
looked  for,  and  on  the  inner  surface  of  the  mucous  mem- 
brane of  the  lips  and  cheeks.  This  secondary  lesion, 
which  is  also  known  as  a  mucous  patch,  may  in  rare  cases 
occur  on  the  nasal  mucous  membrane,  either  on  the  sejv 
tum  or  on  the  anterior  portion  of  the  floor  of  the  nose  ; 
while  a  broad  condyloma  which  represents  an  extreme 
hypertrophy  of  the  papillary  bodies  sometimes  occurs  on 
the  mucous  membrane  of  the  turbinates  or  in  the  naso- 
pharynx in  the  form  of  a  moderately  raised  growth  resem- 
bling a  cock's-comb,  or  at  the  entrance  to  the  nose  in  the 


78  SPECIAL  PATHOLOGY  AND  TREATMENT. 

form  of  a  diffuse,  dry,  brownish-red,  somewhat  elevated 
infiltration  surrounded  by  rhagades. 

In  the  mouth  and  pharynx  condylomata  present  them- 
selves in  the  form  of  broad,  more  or  less  elevated,  brown- 
ish-red or  bluish  elevations,  with  a  shallow  central  de- 
pression and  superficial  ulceration  (Plate  2,  Fig.  1 ;  Plate 
17,  Fig.  2). 

The  course  of  all  these  lesions  is  quite  protracted. 
Several  weeks  at  least  are  required  for  the  occurrence  of 
spontaneous  involution,  but  a  well-trained  physician  will 
hardly  be  inclined  to  wait  for  this  to  take  place.  The 
lesions  may  ulcerate  and  break  down  or  even  become  gan- 
grenous, owing,  probably,  to  mixed  infection,  especially 
in  anemic  individuals. 

The  diagnosis  in  a  well-marked  case  presents  no  dif- 
ficulties ;  but  in  the  early  stage,  when  the  disease  is,  as 
we  know,  extremely  infectious,  it  is  more  difficult  and  all 
the  more  important.  Attention  has  already  been  called 
to  the  disproportionate  severity  of  the  pain.  In  addition, 
all  the  lymph-glands  in  the  corresponding  region  early 
become  enlarged.  The  patient  suffers  from  marked 
general  malaise  and  may  have  slight  fever;  in  women 
there  is  often  a  good  deal  of  falling  out  of  the  hair.  The 
diagnosis  is  established  beyond  a  doubt  by  the  presence 
or  speedy  development  of  the  characteristic  eruption  or 
by  the  discovery  of  a  freshly  healed  primary  lesion.  The 
patient's  statements  are  of  value  only  when  they  are  posi- 
tive— quivis  syphiliticus  mendax. 

Treatment. — Local  measures  are  required  in  addition 
to  energetic  mercurialization.  Cauterization  with  chromic 
acid  applied  at  the  end  of  a  probe  and  repeated  at  inter- 
vals of  two  to  three  days  has  been  found  extremely  use- 
ful, both  to  allay  the  pain  and  to  hasten  involution.  Con- 
dylomata in  the  nose  may  be  treated  with  powdered  calo- 
mel or  with  white  precipitate  ointment. 

The  tendency  of  the  mucous  patches  to  recur  deserves 
special  mention.  This  tendency  is  due  to  artificial  irrita- 
tion of  the  diseased  mucous  membrane,  which  for  some 


SYPHILIS.  79 

time  continues  to  be  extremely  sensitive,  by  food,  tobacco, 
or  other  irritating  substances.  It  is  not  an  indication  to 
renew  mercurial  treatment,  especially  as  mercurial  stoma- 
titis itself  may  produce  circumscribed  cloudy  swelling  of 
the  epithelium.  Under  these  circumstances  an  expectant 
policy  and  careful  supervision  are  called  for,  and  it  is  to 
be  remembered  also  that  any  phenomena  of  this  kind  that 
are  unduly  prolonged  must  not  at  once  be  pronounced 
syphilitic.  Superficial  maceration  of  the  raucous  mem- 
brane from  general  pharyngostomatitis,  especially  when 
it  is  of  the  secondary  character  described,  may  occur 
whether  the  individual  is  clearly  syphilitic  or  entirely 
innocent  of  luetic  taint  (see  Plate  10,  Fig.  1).  The  con- 
dition may  be  recognized  by  the  entire  absence  of  any 
tendency  to  undergo  progressive  alteration. 

In  contradistinction  to  the  comparative  frequency  of 
these  secondary  phenomena,  a  primary  lesion  of  the  mucous 
membnine  is  extremely  rare,  as  the  infection,  of  course, 
usually  gains  entrance  by  way  of  the  sexual  organs. 
Nevertheless,  chancres  have  been  observed  in  every  por- 
tion of  the  oropharynx  and  of  the  interior  of  the  nose, 
and  even  in  the  inaccessible  nasopharynx.  The  tonsils 
are  most  frequently  attacked,  as  the  open  crypts  are  very 
accessible  to  infective  material,  transmitted  by  kissing, 
aspirated,  or  otherwise  introduced  into  the  mouth,  such 
as  by  glassblowers'  pipes,  needles,  and  the  like. 

The  diagnosis  is  very  often  delayed  until  the  appearance 
of  secondary  symptoms  direct  the  physician's  attention  to 
the  original  morbid  process,  which  for  weeks  had  escaped 
his  notice.  In  some  cases,  however,  when,  as  is  the  case 
in  certain  constitutions,  the  pain  is  marked,  the  physician's 
attention  or  even  his  suspicions  may  be  awakened  and 
led  on  the  right  track.  The  chancre  is  differentiated  from 
secondary  lesions  by  the  distribution,  which  is  generally 
unilateral,  by  the  circumscribed,  deep,  and  indurated 
(cartilaginous)  infiltration  and  the  thickened  and  elevated 
edges.     No  one  can  be  blamed,  however,  for  failing  to 


80  SPECIAL  PATHOLOGY  AND  TREATMENT. 

make    the  diagnosis  before  the   outbreak  of  generalized 
syphilis. 

The  treatment  of  the  lesion  is  purely  symptomatic. 

In  the  foregoing  description  only  the  diifuse,  acute  in- 
flammations have  been  included.  The  special  localiza- 
tions of  acute  inflammation,  especially  in  the  accessory 
sinuses  of  the  nose,  are  either  so  recondite  or  else  their 
diagnosis  and  treatment  are  so  nearly  the  same  as  those 
of  chronic  inflammations  in  the  same  regions,  that  for  the 
sake  of  simplicity  they  will  be  discussed  at  the  same  time 
with  the  permanent  affections  of  these  regions. 

CHRONIC   INFLAMMATIONS. 

Chronic  inflammations  of  the  upper  mucous  membranes 
either  result  from  repeated  acute  attacks,  or  follow  a  single 
severe  acute  inflammation  of  excessively  great  virulence, 
which  does  not  produce  self-limited  sequelae,  or,  finally, 
they  may  result  from  the  localization  of  the  process  in 
some  region  structurally  unfavorable  for  recovery.  Con- 
stantly acting  injuries,  such  as  decayed  teeth,  alcohol, 
tobacco,  especially  when  chewed  or  taken  in  the  form  of 
snuff,  occupational  injuries,  and  irritation  from  flour,  street- 
dust,  cement,  chromic  acid,  arsenic  vapors,  and  the  like,  are 
all  apt  to  produce  chronic  catarrh.  The  injurious  effect  of 
abnormal  secretions  from  the  nose  and  nasopharynx  acting 
on  the  intermediate  and  deeper  mucous  membranes  of  the 
mouth  and  throat  is  also  to  be  considered.  Tliis  mode 
of  origin  is  quite  frequently  overlooked,  and  accordingly 
all  manner  of  treatment,  including  balneotherapy,  is 
applied  in  vain.  The  anatomic  basis  of  chronic  inflam- 
mations is  naturally  as  manifold  as  the  complicated  sys- 
tem of  cavities  and  recesses  itself. 

In  the  mouth  the  tongue  is  found  to  be  slightly  coated 
and  reddened  at  the  margins.  Owing  to  the  swelling  of 
the  member,  it  shows  numerous  tooth-marks  and  small 
wounds  inflicted  during  hasty  mastication  on  account  of 


CHRONIC  INFLAMMATIONS.  81 

its  thickened  condition,  which  somewhat  interferes  with 
free  movement.  The  gums  frequently  show  alterations ; 
there  is  a  clouding  of  the  epithelium,  which  later  becomes 
swollen  and  livid  from  passive  hyperemia.  They  push 
themselves  into  the  interstices  between  the  teeth,  or,  on  the 
other  hand,  become  retracted  on  the  anterior  surfaces  so 
as  partly  to  expose  the  roots  (Plate  4,  Fig.  2).  Some- 
times the  mucous  membrane  becomes  loosened,  and  pyor- 
rhoea alveolaris,  or  suppuration  from  the  covering  of  the 
roots  of  the  teeth,  results,  with  loosening  and  falling  out 
of  the  teeth.  These  pathologic  processes,  however,  always 
rest  on  some  constitutional  basis ;  they  are  observed  in 
individuals  weakened  by  protracted  disease,  overexertion, 
or  privation,  or  suffering  from  some  dyscrasic  condition, 
such  as  diabetes,  chronic  nephritis,  tabes,  or  grave  gastric 
catarrh.  It  need  hardly  be  mentioned  that  general  stoma- 
titis and  pharyngitis  are  aggravated  by  extensive  caries 
affecting  the  crowns  and  roots  of  teeth,  nor  can  we  suffi- 
ciently condemn  the  abominable  practice  followed  by  so 
many  dentists  of  utilizing  carious  stumps  for  the  founda- 
tion of  a  set  of  artificial  teeth,  which  necessarily  results 
in  purulent  and  hypertrophic  gingivitis  and  horrible  fetor 
of  the  breath. 

The  mucous  membrane  of  the  cheeks  also  becomes  in- 
volved ;  there  is  swelling,  with  whitish  discoloration ; 
opposite  the  molar  teeth  depressions  are  often  observed, 
caused  by  the  thickened  mucosa  forcing  itself  into  the  inter- 
stices of  the  teeth.  The  irritation  produced  in  the  various 
salivary  glands  manifests  itself  in  ptyalisra.  When  the 
ducts  of  the  salivary  glands  are  much  involved,  the  secre- 
tion becomes  more  tenacious  and  is  more  slowly  secreted  ; 
lime-salts  are  often  produced,  and  are  deposited  in  the 
gland-ducts  in  the  form  of  salivary  calculi. 

The  pharynx  very  frequently  presents  chronic  hyper- 
emia. The  effect  of  hot  and  highly  seasoned  dishes,  to- 
bacco, and  alcohol,  which  the  more  robust  mucous  mem- 
brane of  the  mouth  is  better  able  to  resist,  is  greater  in 
the  pharynx,  because  these  substances,  in  their  passage  to 
6 


82  SPECIAL  PATHOLOGY  AND   TREATMENT. 

the  stomach  or  to  the  lung,  are  momentarily  delayed.  In 
addition,  the  injurious  material  from  tlie  nose  tends  to 
increase  both  the  frequency  and  the  severity  of  inflam- 
matory processes  in  the  pharynx,  which  become  still  fur- 
ther aggravated  by  the  constant  muscular  strain  incident 
to  retching  and  clearing  the  throat  after  aspirating  the 
contents  of  the  nose  and  pharynx.  It  is,  therefore,  unusual 
to  see  an  adult  with  a  really  normal  pharynx.  Slight  swell- 
ing of  the  pillars  of  the  fauces,  with  lo(!alized  areas  of  in- 
tense redness  on  the  posterior  wall  of  the  pharynx,  are 
exceedingly  common  and  do  not  necessarily  produce  any 
unpleasant  symptoms.  Dilatation  of  the  veins  is  another 
condition  that  is  commonly  observed,  especially  when,  as 
is  usually  the  case  in  civilized  human  beings,  tliere  is  more 
or  less  abdominal  stasis  due  to  delayed  digestion,  and 
when  the  individual  is  suffering  from  circulatory  disease 
of  the  heart,  cirrhosis  of  the  liver,  tumors,  or  any  other 
condition  that  interferes  with  the  circulation. 

The  lymph-follicles  are  involved  in  almost  every  case 
of  chronic  catarrh.  There  maybe  diffuse  swelling,  causing 
a  velvety,  mammillated  appearance  of  the  surface  or  a 
circumscribed  hypertrophy  on  the  post<^rior  wall  of  the 
pharynx  and  on  the  pillars  of  the  fauces  (Plate  13,  Fig.  1). 
The  latter  condition  is  known  as  pharyngitis  granulosa  or 
lateralis  hypertrophica.  These  nodules,  it  is  true,  not 
infrequently  represent  the  remains  of  lymphatic  hyper- 
plasia without  any  inflammatory  basis,  and  may  even  be 
imbedded  in  an  anemic  mucous  membrane. 

Syphilis  appears  to  have  a  special  tendency  to  leave 
behind  a  chronic  inflammation,  which  is  preferably  epi- 
thelial in  character.  It  may  take  the  place  of  the  erup- 
tions on  the  mucous  membrane  just  referred  to,  or  may 
present  a  more  diffuse  character,  and  is  usually  associated 
with  atrophic  processes  in  the  connective  tissue.  Thus, 
opaque  white  patches  often  persist  for  years  after  secon- 
dary manifestations  of  the  disease,  and  are  not  infre- 
quently mistaken  for  mucous  patcihos.  In  recently  in- 
fected cases  one  sees  the  peculiar  picture  of  leukoplakia 


CHRONIC  INFLAMMATIONS.  83 

oris,  which,  however,  is  in  part  produced,  or  at  least  aggra- 
vated, by  gastric  catarrh,  excessive  smoking,  and  especially 
by  secondary  catarrli  derived  from  the  nose,  to  which 
is  superadded  the  deleterious  influence  of  the  nasal 
secretion  in  purulent  nasal  affections.  The  last-mentioned 
causative  factor  acquires  peculiar  importance  from  the 
fact  that  it  often  suffices  to  produce  and  keep  alive  the 
somewhat  rare  affection  under  discussion,  even  when  there 
has  been  no  syphilitic  infection.  The  disease  chiefly 
attacks  the  anterior  portions  of  the  mouth.  The  margin 
and  anterior  half  of  the  tongue  and  the  mucous  membrane 
of  the  lips  and  cheeks  are  covered  with  a  coating  of 
variable  thickness  and  of  a  color  that  may  be  bluish-white, 
pure  white,  or  somewhat  yellowish,  from  the  presence  of 
food  or  hemorrhages.  The  coating  consists  in  the  main 
of  hyperplasia  and  hyperkeratosis  of  the  epithelium 
(Plate  6,  Fig.  1).  There  are  marked  passive  hyperemia 
and  round-celled  infiltration  of  the  mucosa,  indicating 
the  presence  of  inflammatory  irritation.  Except  for  the 
production  of  painful  fissures  by  the  separation  of  the 
cornified  layers,  there  are  practically  no  subjective  symp- 
toms. The  affection  may  assume  a  serious  character, 
either  in  a  psychic  sense  by  producing  a  condition  of 
syphilophobia,  or,  in  a  more  practical  sense,  as  the  epi- 
thelial proliferation  has  a  tendency  to  become  atypical 
and  degenerate  into  carcinoma. 

A  similar  desquamation  of  the  swollen  epithelial  cov- 
ering is  occasionally  observed  in  the  anterior  portion  of 
the  septum  in  association  with  crust-formation  within  the 
nose.  As  this  position  favors  drying  out  of  the  crusts, 
the  latter  become  densely  adherent,  and  by  their  pressure 
on  the  epithelium  produce  a  superficial  necrosis.  The 
epithelium  becomes  loosened  and  forms  a  thin  white  mem- 
brane, Aviiich,  after  a  time,  can  be  removed  with  the  for- 
ceps without  producing  a  hemorrhage,  leaving  the  mucosa 
exposed  (Plate  27,  Fig.  3). 

This  process  would  be  observed  more  frequently,  but 
the  crusts  are  usually  separated  prematurely  by  scratching 


84  SPECIAL  PATHOLOGY  AND   TREATMENT. 

and  squeezing  the  nose,  and  tlie  repeated  traumatism  and 
resulting  suggillations  eventually  lead  to  ulceration  and 
necrosis,  even  of  the  underlying  cartilage,  so  that  perfora- 
tion ultimately  remains.  In  itself  this  process  is  quite 
harmless,  but  it  is  annoying  to  the  patient  on  account  of 
the  vicious  circle  established  by  the  alternate  removal 
and  formation  of  the  crusts.  It  is  generally  associated 
with  obstruction  of  the  nose  and  a  feeling  of  tension,  and, 
in  addition,  is  not  without  significance  on  account  of  the 
danger  of  erysipelas  and  otiier  infections.  It  may  be 
mistaken  for  syphilis.  The  differential  diagnosis  must  be 
based  on  the  duration  of  the  process,  the  typical  position 
of  the  lesions  within  reach  of  the  scratching  finger,  and 
the  normal  condition  of  the  immediate  surroundings.  A 
failure  to  appreciate  the  purely  traumatic  origin  of  the 
process  has  led  to  the  description  of  individual  stages  of 
it  as  "xanthosis" — that  is,  hemorrhagic  infiltration  or 
deposition  of  hemoglobin  fragments,  and  as  "  perforating 
ulcer  of  the  septum." 

In  the  nasopharynx  chronic  catarrh  is  met  as  a 
constant  concomitant  of  adenoid  vegetations  (see  p.  149), 
even  when  the  latter  are  of  only  moderate  extent.  The 
localization  of  these  growths  in  the  recesses  of  the 
nasopharynx  is  discussed  on  page  141.  In  most  cases 
the  diagnosis  of  nasal  catarrh  is  quite  proper,  as  in  90 
out  of  100  cases  the  accumulation  of  secretion  or  crusts 
in  the  nasopharynx  is  dne  to  some  nasal  process  (see 
Plate  22,  Fig.  2 ;  Plate  24,  Fig.  2). 

Chronic  nasal  catarrh  always  involves  the  erectile 
tissues,  which  readily  respond  to  any  form  of  irritation 
on  account  of  their  great  reflex  liability  to  dilatation. 
The  hyperemia,  especially  when  it  affects  the  inferior 
turbinates,  may  at  first  escape  the  subject's  notice  for 
some  time,  because  in  mild  cases  the  swelling,  as  a  rule, 
alternates  from  one  side  to  the  other,  permitting  sufficient 
air  to  enter  through  the  opposite  side.  During  sleep, 
however,  the  amount  of  air  usually  proves  insufficient, 
and  mouth-breathing  occurs,  so  that,  on  being  questioned, 


CHRONIC  INFLAMMATIONS.  85 

or  sometimes  of  his  own  accord,  the  patient  admits  that 
he  has  a  feeling  of  dryness  in  the  throat  in  the  morning. 
If  the  hyperemia  persists,  it  soon  degenerates  into  dif- 
fuse hyperplasia  of  all  the  various  constituents  of  the 
mucous  membrane  or  at  least  into  hypertrophy  of  some 
of  these  constituents.  The  inferior  turbinates,  which  are 
more  frequently  involved  in  the  former  case,  present  the 
same  thickening  as  in  simple  hyperemia,  with  the  differ- 
ence that  they  do  not  shrink  after  the  vascular  engorge- 
ment has  subsided.  Hence  cocain  is  used  for  purposes 
of  differentiation.  A  1  per  cent,  solution  suffices  to  cause 
a  simple  hyperemia  to  disappear,  and  if,  after  its  applica- 
tion, any  thickening  remains,  especially  if  it  is  confined 
to  circumscribed  portions,  such  as  the  anterior  or  pos- 
terior extremity  or  the  upper  margin  of  the  inferior  tur- 
binate, it  is  a  sign  of  true  hyperplasia. 

The  hyperplasia  most  frequently  takes  the  form  of 
smooth,  round,  club-shaped  thickening  of  the  extremities 
of  the  inferior  turbinate,  in  which  all  the  elements  of  the 
tissues  except  the  epithelium  participate  (Plate  27,  Fig.  1). 
Beginning  proliferation  of  the  latter  manifests  itself  at 
first  in  the  formation  of  wrinkles  on  the  surface  (Plate  28, 
Fig.  2),  then  in  lobulation  and  papillary  new  growths 
(Plate  26,  Fig.  1).  The  latter  occupy  preferably  the 
posterior  extremities  of  the  inferior  turbinates,  where  they 
often  present  a  mulberry-like  appearance,  or  they  may  be 
found  on  the  anterior  extremities,  or  on  the  middle  tur- 
binates (Plate  28,  Fig.  2),  and  very  rarely  on  the  septum 
(Plate  27,  Fig.  4)  or  on  the  floor  of  the  nose. 

The  histologic  classification  of  these  growths  depends 
on  the  preponderance  of  the  individual  tissue  elements ; 
thus,  we  speak  of  adenoma  (Plate  35,  Fig.  1);  adeno- 
fibroma  and  angiofibroma  (Plate  33,  Fig.  1) ;  papillary 
fibroma  and  fibro-epithelioma  (Plate  39 ;  Plate  40, 
Fig.  1) ;  or,  finally,  cystadenoma  when  a  gland  has  be- 
come occluded  and  converted  into  a  cyst.  It  is  an  indi- 
cation of  the  inflammatory  origin  of  the  process  that  it 
is  invariably  found  attended  with  round-cell  infiltration 


86  SPECIAL  PATHOLOGY  AND  TREATMENT. 

about  the  glands  and  particularly  about  the  vessels.  The 
walls  of  the  latter  sometimes  undergo  eccentric  prolifera- 
tion and  sometimes  proliferate  concentrically  to  such  an 
extent  as  to  produce  local  interference  with  the  circula- 
tion and  stagnation  of  the  plasma  and  lymph  (Plate  33, 
Fig.  2).  It  is  the  latter  process  that  is  especially  con- 
cerned in  the  production  of  edematous  fibromata,  the  so- 
called  mucous  polypi  (Plate  26,  Fig.  2  ;  Plate  28, 
Fig.  1).  These  peculiar  structures  consist  mainly  of  loose 
connective  tissue  infiltrated  with  serous  fluid  or  distended 
to  actual  cyst-formation,  containing  both  straight  and 
elastic  fibers  and  numerous  inflammatory,  hypertrophied, 
and  even  obliterated  blood-vessels  (Plate  33,  Fig.  2). 
Clinically,  they  appear  as  smooth  tumors  ranging  in  color 
from  grayish-yellow  to  pale  pink.  The  tumors  are  usually 
discrete  and  very  small,  and  are  situated  somewhere  in  the 
region  of  the  middle  nasal  meatus.  Not  uncommonly, 
however,  they  appear  in  considerable  and  often  incredible 
numbers,  and  attain  a  stupendous  size,  growing  by  a  long 
pedicle  from  the  middle  and  superior  turbinates,  or  even 
from  the  interior  of  an  accessory  cavity,  and  projecting 
into  the  interior  of  the  nose.  The  author  has  counted  as 
many  as  120  in  a  single  nose,  the  largest  of  them  weigh- 
ing 28  grams.  In  exceptional  cases  they  appear  to  de- 
velop spontaneously,  and  after  their  removal  leave  no 
alteration  of  the  nasal  cavity  except  a  more  or  less  exten- 
sive pressure  atrophy  of  the  internal  nasal  skeleton.  In 
these  cases,  which  almost  always  occur  in  persons  of 
advanced  age,  there  are,  as  a  rule,  large  masses  of  polypi. 
On  the  other  hand,  in  about  85  per  cent,  of  all  the  cases, 
polypi  are  symptomatic  in  character  and  represent  the 
product  of  some  deeper  inflammatory  condition,  which 
should,  therefore,  always  be  searched  for  in  every  case  of 
polyp-formation.  The  persistence  of  the  basal  condition 
often  explains  the  well-known  tendency  of  these  tumors 
to  recur  even  after  apparently  radical  extirpation — so 
much  so  that  they  are  often  regarded  as  incurable  not 
only  by  the  laity,  but  also  by  practitioners.     It  cannot 


CHRONIC  INFLAMMATIONS.  87 

be  said,  however,  that  a  basal  inflammation  is  the  sole 
cause.  It  often  happens  in  chronic  cases  that  polypi  con- 
tinue to  make  their  appearance  even  after  a  thorough 
correction  of,  let  us  say,  purulent  catarrh  of  an  accessory 
sinus,  and  it  is  not  to  be  denied  that  there  are  many  cases 
of  recurring  polypi  without  any  focal  suppuration.  In 
both  conditions  the  proliferation  has  extended  to  the 
periosteum  and  to  the  bone,  or  it  began  originally  in 
these  structures ;  and,  in  order  to  arrest  the  progress  of 
the  abnormal  growth,  it  becomes  necessary  to  remove 
these  structures,  although  the  original  cause  in  both  cases 
may  already  have  been  removed.  Even  in  cases  unasso- 
ciated  with  focal  suppuration  the  whole  structure  of  the 
tumors  indicates  an  inflammatory  process ;  on  the  other 
hand,  one  should  not  go  to  the  other  extreme  of  making 
the  general  statement  that  all  polypi  grow  from  perios- 
teum or  take  their  origin  in  an  inflammatory  osteomyelitis. 
The  latter  condition  is  only  occasionally  found.  It  can- 
not in  any  sense  be  said  to  be  the  rule,  and  is  more  apt 
to  be  a  sequel  than  the  causal  condition,  a  fact  which  is 
shown  both  by  the  negative  histologic  findings  and  by 
the  circumstance  that  a  number  of  cases  of  polypi  asso- 
ciated with  focal  suppuration  either  disappear  sponta- 
neously or  fail  to  return  after  the  first  removal,  providing 
only  the  focal  suppuration  has  been  cured. 

Another  cause  of  recurrence  is  found  in  the  circum- 
stances already  referred  to,  that  the  polypi  that  are  visible 
in  the  nose  have  their  roots  in  the  mucous  membrane  or 
periosteum  of  the  accessory  sinuses.  This  is  especially 
true  in  the  case  of  the  ethmoid  cells,  which  are,  relatively 
speaking,  accessible,  but  it  is  also  true  to  some  extent  of 
the  other  pneumatic  spaces.  The  tumors  growing  in 
them  are  usually  small  and  do  not  exceed  in  size  the 
cavities  themselves,  especially  the  larger  ones.  These 
tumors  are  never  seen  except  during  an  operation  or  at 
the  autopsy. 

A  special  feature  of  the  mucous  membrane  lining  the 
accessory   cavities  is   the   presence   of   cysts   consisting 


88  SPECIAL  PATHOLOGY  AND  TREATMENT. 

usually  of  serous  effusions  into  the  lymph-spaces,  or, 
rarely,  of  a  dilated  gland-duct  that  has  been  constricted. 
The  walls  of  these  cysts  are  formed  of  an  extremely  thin 
layer  of  connective  tissue  covered  with  flat  epithelial 
cells,  and  corresponding  in  every  respect  to  the  extremely 
delicate  lining  membrane  of  the  cavities,  which  it  is  prac- 
tically impossible  to  separate  from  the  periosteum.  Owing 
to  the  protected  position  of  these  cavities  and  the  impos- 
sibility of  their  being  affected  by  any  external  injuries, 
such  as  would  utterly  preclude  the  formation  of  similar 
structures  within  the  nose,  they  occasionally  attain  a  con- 
siderable size.  In  the  antrum  of  Highmore  the  cystic 
change  may  lead  to  pressure-atrophy  of  the  bone  and 
bulging  of  the  walls,  a  condition  which  has  been  described 
under  the  name  of  hydrops  of  the  antrum  of  Highmore. 
The  only  mucous  cysts  found  in  the  interior  of  the  nose 
are  included  within  tumors  and  are  produced  by  dilata- 
tion of  a  gland  (Plate  34)  or  by  softening  of  edematous 
polypoid  tissue.  The  contents  of  such  cysts  are  of  an 
amber  color,  and  so  tenacious  that  the  distinction  from 
polypi  is  extremely  difficult,  and  in  frozen  sections  quite 
impossible. 

In  marked  contrast  to  these  swellings  and  true  tumor- 
formations  produced  by  chronic  inflammation  are  the 
atrophic  processes,  or,  more  correctly,  conditions 
which  rest  on  the  same  etiologic  basis.  These  atrophic 
conditions  are  also  met  in  the  mouth.  Abnormal  dryness 
of  the  oral  mucous  membrane  occurs  not  only  from  oral 
respiration,  but  also  as  the  result  of  persistent,  especially 
secondary,  catarrh,  and  is  then  due  to  atrophy  of  the 
mucous  and  salivary  glands,  although  the  development 
of  the  condition,  as  in  the  case  of  dryness  of  the  nasal 
and  pharyngeal  mucous  membrane,  presupposes  an  indi- 
vidual predisposition  which  rests  on  malnutrition  of  the 
mucous  membrane,  either  congenital  or  acquired  during 
childhood.  The  contraction  of  interstitial  tissue  observed 
in  the  catarrh  of  scarlet  fever,  and  more  especially  in 
syphilis,  including  the  hereditary  forms,  which  so  often 


CHRONIC  INFLAMMATIONS.  89 

remain  masked,  and  syphilis  acquired  in  childhood,  with 
its  accompaniment  of  extensive  vascular  alterations,  prob- 
ably represent  the  chief  structural  foundation,  while,  on 
the  other  hand,  the  very  common  occurrence  of  "  atro- 
phies" in  districts  showing  high  percentage  of  rachitic 
individuals  would  tend  to  indicate  that  general  nutritive 
disturbances  also  play  an  important  part  in  the  etiology. 
It  follows  that  atrophic  processes,  which,  in  their  early 
stages,  manifest  themselves  by  dryness  of  the  mucous 
membrane,  call  for  careful  examination  of  the  general 
condition.  Latent  diabetes,  for  instance,  is  very  apt  to 
give  the  first  signs  of  its  presence  in  this  way. 

Appearances  indicative  of  atrophy  in  the  mouth  are 
not  very  conspicuous.  In  the  pharynx,  however,  they 
are  quite  marked.  The  mucous  membrane  of  the  poste- 
rior wall  of  the  pharynx  presents  pale,  glistening,  linear 
markings  that  reflect  the  light  and  are  due  to  wrinkling 
of  the  attenuated  mucosa.  In  the  higher  grades  of  atrophy 
the  soft  palate  and  uvula  are  greatly  shrunken.  But 
it  is  in  the  nose  that  the  alterations  due  to  atrophy  are 
most  conspicuous.  In  advanced  cases  the  mucous  mem- 
brane barely  suffices  to  veil  the  skeleton.  The  outlines 
of  the  turbinates,  which,  under  normal  conditions,  owing 
to  the  robust  covering  of  erectile  tissue,  appear  like 
thick,  club-shaped  bodies,  contract  to  such  an  extent  as 
to  leave  an  unobstructed  view  from  the  inferior  meatus  as 
far  as  the  nasopharynx  ;  and,  by  looking  along  the  middle 
turbinate,  the  otherwise  invisible  superior  turbinate,  and 
even  the  roof  of  the  nose,  is  distinctly  seen.  The  epithelium 
is  also  attacked  by  the  atrophic  process ;  the  walls  of  the 
nose  dry  out,  the  juicy,  cylindric  cells  become  converted 
into  flat,  horny  elements  which  slowly  exfoliate  and  accu- 
mulate in  several  layers.  In  exposed  areas,  such  as  the 
angle  of  the  mouth,  the  entrance  to  the  nose,  and  the  front 
of  the  septum,  the  brittle  surface  is  frequently  broken, 
fissures  are  produced,  and  become  covered  with  tenacious, 
adherent  crusts. 

It  follows,  as  a  matter  of  course,  that  a  mucous  mem- 


90"        SPECIAL  PATHOLOGY  AND  TREATMENT. 

brane  which  has  been  altered  pathologically  will  present 
secretory  anomalies.  Accordingly,  chronic  catarrh 
in  the  great  majority  of  cases  is  characterized  by  quanti- 
tative and  qualitative  changes  in  the  secretion.  All  gra- 
dations occur,  rangijig  from  fluid,  almost  watery,  secretion 
or  glairy  and  whitish-gray  mucus  that  can  be  drawn  into 
threads,  to  thick  gray,  grayish-yellow,  greenish,  and  yel- 
low lumps  and  purulent  masses,  both  solid  and  liquid, 
either  yellow  or  greenish-yellow  in  color.  In  addition, 
crusts  of  varying  thickness  and  a  great  variety  of  dis- 
colorations  from  the  admixture  of  blood  are  observed. 
When  the  secretion  stagnates  in  the  cavities  of  the  nose, 
as  happens  in  greatly  dilated  nasal  chambers,  horribly 
offensive  crusts  are  produced,  which  have  given  the 
generic  name  of  "  ozena  "  to  a  great  variety  of  clinical 
pictures. 

Even  in  the  earliest  times,  when  only  the  most  conspic- 
uous nasal  diseases  were  studied,  the  occurrence  of  ex- 
cessive secretion  in  extreme  cases,  drenching  the  pillow 
night  after  night,  and  the  phenomenon  of  a  periodic  cessa- 
tion of  secretion,  followed  by  sudden  renewed  copious 
discharge,  led  investigators  to  examine  into  the  origin  of 
the  secretion,  and  recently  thinking  physicians  have  settled 
this  question  for  all  time.  It  has  been  found  that  under 
all  circumstances  a  rigid  distinction  must  be  drawn  between 
diffuse  and  nasal  catarrh,  and  on  this  distinction  a  rational 
therapeusis  will  depend.  If  abnormal  secretion  is  to  be 
combated,  it  is  absolutely  essential  in  the  first  place  to 
know  where  it  comes  from,  and  it  must  be  remembered 
that  while  the  nose  contains  a  large  area  of  secreting 
mucous  membrane,  it  also  forms  the  drainage  canal  of  a 
number  of  possible  sources  of  secretion  behind  and  around 
it.  It  is  evident  that  an  examination  of  these  sources  in 
every  individual  instance  is  impossible,  and  the  physician 
will,  therefore,  ask  himself  whether  he  has  to  do  with  a 
diffuse  or  with  a  localized  (focal)  process. 

A  theoretic  discussion  of  this  question  does  not  come 
within  the  scope  of  this  volume,  and  the  author  will  con- 


DIFFUSE  FORMS— FOCAL  DISEASES.  91 

fine  himself  to  the  enumeration  of  facts  that  rest  on  the 
basis  of  experience. 


DIFFUSE  FORMS. 

Diffuse  chronic  secretions  of  the  nose  are  extremely 
rare.  Secretions  containing  cellular  elements,  or,  in  other 
words,  consisting  of  any  kind  of  pus,  practically  always 
emanate  from  certain  definite  regions,  even  when  the  dis- 
charge is  small  in  amount,  for  the  nasal  mucous  membrane 
in  general  possesses  such  perfect  mechanical  drainage, 
and  is  so  freely  exposed  to  desiccation  by  the  air,  that  a 
generalized  hypersecretion  soon  ceases  of  its  own  accord, 
except  for  residual  processes  in  areas  which  are  not  access- 
ible to  the  favorable  healing  factors  referred  to,  where, 
accordingly,  a  focal  inflammation  remains  as  a  residuum. 
Even  an  unmixed  mucous  secretion  can  become  inspis- 
sated for  any  length  of  time  only  under  certain  conditions 
interfering  with  free  escape  of  the  fluid,  as  in  hyperemia 
and  hyperplasia  of  the  turbinates  and  other  similar  con- 
ditions. There  is  only  one  form  of  hypersecretion — the 
unmixed  watery  variety,  especially  when  it  occurs  parox- 
ysmally — that  is  more  often  diffuse  than  localized,  and 
even  then  diffuse  only  in  the  sense  that  it  emanates  from 
a  large  smooth  surface,  the  superior  nasal  meatus,  and 
that  it  does  not  become  stagnant.  In  every  case,  there- 
fore, it  will  be  well  to  bear  in  mind  the  possibility  of  a 
focal  origin. 


FOCAL  DISEASES. 


NASOPHARYNX. 


The  nasopharynx  is  an  exceedingly  common  source  of 
secretion,  or,  to  speak  more  precisely,  hypersecretion  is 
apt  to  develop  in  hypertrophy  of  the  turbinates  secondary 
to  disease  of  the  lymphatic  ring.  The  secretion  usually 
becomes  visible  on  the  floor  of  the  nose  in  the  form  of 
thick  clumps  of  mucus.     Whenever  these  are  found  in  a 


92  SPECIAL  PATHOLOGY  AND  TREATMENT. 

nose  otherwise  free  from  secretion,  posterior  rhinoscopy 
should  be  at  once  performed,  a  step  which,  in  fact,  should 
never  be  neglected  under  any  circumstances.  If  nothing 
is  found  on  rhinoscopic  examination,  or  if,  after  the  naso- 
pharynx is  cleared,  the  secretion  continues,  a  fresh  source 
must  be  looked  for.  Frequently  the  mucus,  which  is 
usually  very  tough  and  yellowish  in  color,  drips  down 
over  the  posterior  wall  of  the  pharynx,  and  in  adults  not 
rarely  leads  to  secondary  laryngeal  affections.  At  the 
entrance  to  the  nose  secretion  usually  takes  the  form 
of  crusts.  It  is  only  in  exceptional  cases  that  these  crusts 
are  due  to  inflammation  localized  at  the  site  of  their 
appearance.  As  a  rule,  the  secretion  has  come  from  some 
point  in  the  interior,  and  has  been  deposited  in  this  sit- 
uation, which  is  most  favorable  to  desiccation,  or  else  the 
inflammation  of  the  follicles  of  the  vibrissas  which  has 
produced  the  crusts  is  kept  alive  by  some  more  deeply 
seated  suppurative  process.  Under  any  circumstances 
local  treatment  is  necessary.  The  crusts  are  closely  ad- 
herent and  must  be  softened  up  by  the  introduction  of  a 
cotton-wound  applicator  saturated  with  liquid  vaselin 
(see  p.  46).  Follicles  that  are  infiltrated  with  pus,  acne 
pustules,  and  furuncles,  or  deeper  and  more  wide-spread- 
ing infiltrations,  such  as  phlegmons,  must  be  laid  open. 
Eczema  of  the  skin  surrounding  the  vestibule  must  be, 
at  least  temporarily,  cured  by  means  of  ointments  which 
at  the  same  time  prevent  reinfection  from  within.  In 
children  particularly,  and  usually  also  in  adults,  the  most 
frequent  cause  is  the  presence  of  "  adenoids  "  (see  p.  147). 
As  long  as  the  causal  maceration  by  the  internal  secretion 
continues,  a  return  of  the  folliculitis  must  be  prevented  by 
the  constant  application  of  an  ointment.  A  fresh  attack 
may  be  aborted  by  the  introduction  of  cotton  pledgets 
saturated  in  a  2  per  cent,  solution  of  aluminium  acetate ; 
after  that  the  deep  source  of  the  secretion,  which  is  usually 
one  of  the  smaller  accessory  sinuses,  must  be  diligently 
looked  for. 

A   rare  cause   of  phlegmonous   inflammation  of  the 


FOCAL  DISEASES.  93 

anterior  portion  of  the  nose  is  disease  of  the  roots  of  the 
incisors.  The  absence  of  folliculitis,  which  is  the  usual 
port  of  entry,  and  the  fact  that  the  inflammation  is  re- 
stricted to  the  mucous  membrane  at  the  entrance  to  the 
nose,  should  direct  the  attention  to  the  possibility  of  this 
pathogenesis. 

NASAL  PASSAGES. 

While  the  nasal  passages  very  frequently  serve  merely 
as  the  receptacles  for  secretion  which  has  its  origin  else- 
where, they  may  also  be  the  primary  seat  of  disease. 

The  inferior  meatus  collects  the  secretions  of  the  lacri- 
monasal  duct  and  of  the  conjunctiva.  As,  however,  the 
latter  organs  are  quite  apt  to  become  involved  secondarily 
through  the  accumulation  of  a  secretion  in  the  inferior 
meatus  and  the  propagation  of  an  inflammation  primary 
in  that  region,  one  is  not  justified  in  assuming  the  ocular 
condition  to  be  primary  unless  distinct  ocular  disease  can 
be  demonstrated,  and  the  boundaries  of  the  inferior  nasal 
meatus  are  not  materially  altered.  The  latter  is  almost 
always  the  case  when  large  masses  of  mucopus,  such  as 
frequently  accompany  hyperplasia  of  the  pharyngeal  ton- 
sils, are  present.  It  is  to  be  remembered  that  frequent  as 
hyperplasia  of  the  tonsils  may  be,  consecutive  swelling  of 
the  inferior  turbinate  is  equally  frequent ;  it  may  be  so 
great  as  completely  to  obstru(;t  the  inferior  meatus  and 
thus  lead  to  the  production  of  copious  secretion.  The 
question  whether  this  accumulation  belongs  to  the  meatus 
itself  or  has  made  its  way  forward  from  the  nasopharynx 
is  best  decided  by  removing  the  tonsil  and  observing 
whether  the  process  continues  or  becomes  arrested.  It  is 
true  that  in  the  former  event  the  secretion  may  come  from 
one  of  the  accessory  sinuses,  especially  the  antrum ;  while 
this  is  rare  in  children,  it  has  been  repeatedly  observed. 
If  the  discharge  is  confined  to  one  side,  its  origin  from 
the  antrum  is  practically  certain,  and  even  when  it  is 
bilateral,  that  possibility  is  not  to  be  excluded  d,  priori. 
But  in  the  great  majority  of  cases  of  this  kind  one  has  to 


94  SPECIAL  PATHOLOGY  AND  TREATMENT. 

deal  with  a  simple  catarrh  of  the  nasal  ra(!atus,  which 
soon  disappears  if  the  secretion  is  systematically  removed 
by  spraying  and  proper  cleansing  of  the  nose,  or  at  least 
after  the  swollen  and  hypertrophied  portions  have  been 
made  to  shrink. 

In  adnlts  not  affected  with  nasopharyngeal  disease  the 
conditions  are  directly  opposite.  It  is  quite  common  to 
find  secretion  only  in  the  inferior  meatus,  but  in  such  a 
case  one  should  carefully  avoid  making  a  hasty  diagnosis 
of  inflammation  of  the  nasal  meatus.  Secretions  derived 
from  the  antrum  and  sphenoid  sinus  are  very  apt  to 
appear  on  the  floor  of  the  nose,  that  from  the  antrum 
being  usually  more  purulent,  more  profuse,  and  in  large 
coherent  masses;  while  that  from  tiie  sphenoid  sinus  is 
more  scanty  and  evinces  a  greater  tendency  to  dry  out. 
The  former  extends  in  a  broad,  invisible  layer  over  the 
upper  and  median  surface  of  the  inferior  turbinate ;  the 
latter  flows  along  the  septum  to  the  floor  of  the  nose. 
The  differential  diagnosis  will  be  materially  facilitated  by 
obstructing  the  suspected  source  of  the  discharge  (see 
p.  38).  A  secretion  coming  from  one  of  the  accessory 
sinuses,  as  long  as  it  remains  fluid,  is  usually  much  more 
copious  than  that  which  is  formed  in  the  nasal  meatus 
and  the  hypertrophies  which  accompany  or  cause  the 
latter,  unless  there  is  a  diffuse  hyperemia  of  the  erectile 
tissue,  are  found  only  at  the  anterior  extremity  of  the 
inferior  turbinate.  That  portion  of  the  turbinate  may 
be  enlarged  to  such  an  extent  as  to  lead  to  the  formation 
of  a  deep  recess  behind  it,  which  can  be  exposed  only  by 
removing  the  extremity  of  the  bone  after  the  method  used 
in  amputating  the  middle  turbinate  (see  p.  50).  This 
condition,  it  is  true,  is  quite  rare,  and  it  may  be  incident- 
ally remarked  that  the  practice  which  has  recently  be- 
come popular  of  amputating  half  or  all  of  the  inferior 
turbinate  rests  on  a  purely  esthetic  foundation. 

Caries  of  neighboring  teeth,  even  without  retention, 
sometimes  leads  to  chronic  irritation  and  hypersecretion 
of  the  mucous  membrane.     Easy  as  it  is  to  remove  the 


FOCAL  DISEASES.  95 

cause  when  it  is  found,  it  is  equally  easy  to  overlook  it  in 
the  first  place. 

Subjective  symptoms  are  rarely  marked  in  diseases  of 
the  inferior  meatus,  although  drawing  pains  in  the  jaw 
and  frontal  headache  sometimes  occur. 

They  are,  on  the  other  hand,  quite  marked  in  the  rather 
rare  chronic  inflammations  of  the  middle  and  superior 
meati.  In  these  conditions  the  discharge  flows  down 
the  median  surface  of  the  middle  turbinate.  Inflamma- 
tion of  the  middle  and  inferior  meatus  is  usually  due  to  an 
acute  catarrh  becoming  chronic  on  account  of  permanent 
hypertrophy  producing  retention.  Like  inflammation  of 
the  accessory  sinuses,  it  is  characterized  by  the  occurrence 
of  dryness,  alternating  with  the  sudden  discharge  of  rela- 
tively large  quantities  of  secretion — relatively,  we  say, 
for  here  also  the  secretion  is  always  much  less  in  quantity 
than  one  emanating  from  accessory  sinuses.  In  making 
the  diagnosis  tiie  pneumatic  spaces  must  first  be  excluded, 
since  the  middle  and  inferior  meati  communicate  with  all 
of  them.  In  some  cases  a  positive  diagnosis  can  be  made 
later  on  only  by  observing  that  the  discharge,  which  in 
these  cases  is  always  purulent,  not  mucous,  heals  without 
local  treatment  directed  to  the  accessory  sinuses.  Stag- 
nation of  the  secretion  in  the  comparatively  small  spaces 
always  produces  a  severe  irritation  of  the  mucous  mem- 
brane, with  intense  migration  of  leukoc^'tes.  Erosions 
and  ulcers  from  the  pressure  of  neighboring  structures 
may  even  invade  the  bone. 

In  the  middle  and  superior  meatus,  the  favorite  seats 
are  the  small  depressions  in  front,  between  the  outer  wall 
of  the  nose  (lamina  papyracea  or  os  planum)  and  septum, 
and  a  little  further  back,  below  the  bend  of  the  middle 
turbinate  or  between  the  latter  and  the  upper  turbinate, 
especiallv  when  the  extremities  of  the  turbinates  are 
thickened  (Plate  29,  Fig.  2).  These  recesses  between  the 
middle  and  upper  turbinates  may  also  be  produced  sec- 
ondarily, and  then  become  an  even  more  violent  source 
of  irritation.     As  the  suppurative  processes  in  the  meatus 


96  SPECIAL  PATHOLOGY  AND  TREATMENT. 

are  kept  up  solely  by  the  retention  of  the  secretions,  the 
parts  must  be  laid  wide  open  to  bring  about  a  cure. 
Owing  to  the  small  dimensions  of  the  spaces,  the  removal 
of  hypertrophies  rarely  suffices,  and  in  most  cases  ampu- 
tation of  the  anterior  extremity  of  the  middle  turbinate 
(see  p.  50)  is  indicated. 

DISEASES  OF  THE  ANTRUM  OF  HIGHMORE. 

Of  the  accessory  cavities,  the  antrum  of  Highmore  is 
more  frequently  involved  than  any  other.  The  current 
conception  of  "  empyema  of  the  antrum  of  Higlimore  "  as 
a  rare  and  severe  disease  is  altogether  erroneous ;  as  a 
matter  of  fact,  it  is  highly  probable  that  the  antrum 
becomes  involved  in  any  violent  acute  catarrh.  It  is  not 
to  be  supposed  that  every  pain  radiating  to  the  teeth  or  to 
the  forehead  is  to  be  referred  to  these  cavities,  but  the 
presence  of  swelling  of  the  infra-orbital  soft  parts,  coupled 
with  periodic  profuse  discharge  of  pus,  should  never  fail 
to  direct  the  diagnostician's  attention  to  them.  The 
diagnosis  can,  however,  be  positively  established  only  by 
exploratory  puncture,  owing  to  the  swelling  and  con- 
sequent difficulty  of  obtaining  a  view  of  the  interior  of 
the  cavity.  Unless  the  pus  comes  from  a  dental  ulcer, 
simple  irrigation,  which  may  be  performed  immediately 
after  the  exploratory  puncture,  will  be  all  the  treatment 
required.  If  this  fails  to  bring  about  a  cure,  all  the 
measures  indicated  in  chronic  inflammations  must  be  tried. 
In  this  connection  we  must  once  more  emphasize  what 
has  already  been  said,  namely,  that  the  antrum  of  High- 
more  is  in  all  probability  the  seat  of  a  chronic  pathologic 
process  more  often  than  any  other  part  of  the  body,  and 
this  statement  is  borne  out  by  the  great  number  of  autop- 
sies in  which  the  antrum  is  found  to  be  involved.  It  also 
proves  that  antrum  disease,  in  the  great  majority  of  cases, 
is  a  benign  process,  and  that,  as  a  matter  of  fact,  it  is 
present  in  all  the  cases  that  are  currently  diagnosed  as 
chronic  nasal  catarrh. 


FOCAL  DISEASES.  97 

As  has  been  remarked  on  p.  91,  persistent  hyper- 
secretion practically  always  has  its  origin  in  circumscribed 
spaces,  and  it  may  here  be  added  that  siich  spaces  are 
principally  found  in  the  antrum  of  Highmore,  especially 
when  the  suspicious  material  consists  mainly  of  mucus. 
It  is  not  improbable  that  the  tenacious  masses  of  muco- 
pus,  which  many  persons  laboriously  expel  on  rising  in 
the  morning  by  aspirating  them  through  the  nose  and 
finally  forcing  them  through  under  the  soft  palate,  are 
derived  from  the  antrum  of  Highmore. 

Approximately  the  same  is  true  of  hypertrophic  condi- 
tions in  the  turbinates.  Both  chronic  hyperemia  and  true 
hyperplasia  of  the  inferior  turbinates  are  very  often  due 
to  catarrh  of  the  antrum  of  Highmore  ;  recurring  condi- 
tions of  this  kind  are  practically  always  due  to  this 
cause.  A  permanent  thickening  of  the  median  border 
of  the  upper  surface  of  the  lower  turbinate,  which  is 
much  more  common  than  the  hyperplasia  of  the  lower  lip 
of  the  hiatus  maxillaris,  also  known  as  the  lateral  fold, 
and  which  occurs  only  in  suppurative  processes,  is  abso- 
lutely pathognomonic  (Plate  27,  Fig.  5). 

Cases  characterized  by  the  discharge  of  yellowish-green 
masses  of  mucus,  gradually  changing  to  a  copious  watery, 
fetid  pus,  are  rare  compared  with  cases  of  more  distinctly 
raucous  catarrh,  but  the  natural  conclusion  that  these 
severer  forms  of  inflammation  must  necessarily  produce 
more  intense  symptoms  is  quite  erroneous.  Profuse  fetid 
discharge  may  exist  without  pain  or  other  subjective 
symptoms,  while,  on  the  other  hand,  the  entire  congeries 
of  nasal  symptoms  described  on  p.  24  may  be  complained 
of  in  cases  in  which  the  catarrh  is  so  inconspicuous  that 
the  patients  themselv^es  often  deny  its  existence.  Without 
pretending  to  draw  a  hard-and-fast  line  between  the 
various  forms  and  degrees  of  hypersecretion,  it  is  advisable 
to  distinguish  between  catarrhs  characterized  by  the  dis- 
charge of  pure  mucus,  mucopus,  an  admixture  in  which 
pus  predominates  over  the  mucus,  and  pure  pus.  The 
second  and  third  forms  are  the  most  frequent.     The  terra 


98  SPECIAL  PATHOLOGY  AND  TREATMENT. 

empyema  should  be  reserved  for  a  collection  of  pus 
within  a  closed  cavity,  a  pathologic  condition  that  is  ex- 
tremely rare.  The  secondary  phenomena  observed  in  the 
nose,  especially  in  the  inferior  turbinate,  have  already 
been  mentioned.  In  addition  the  middle  turbinate,  which 
forms  the  upper  boundary  of  the  hiatus,  is  frequently 
involved.  Hyperplasia  of  the  mucous  membrane  and 
even  true  polypus  formation  are  observed  quite  frequently. 
Occasionally  ulceration  of  the  inferior  lip  or  of  the  lateral 
wall  of  the  middle  turbinate,  extending  as  far  as  the  bone, 
occurs  as  a  result  of  erosion  or  infection  of  the  tissues. 

The  lining  mucous  membrane  of  the  antrum  invariably 
undergoes  certain  alterations.  At  first  it  becomes  in- 
flamed and  thickened  to  a  greater  or  less  degree ;  subse- 
quently the  membrane  becomes  edematous,  and  small 
polypi  are  formed  which  occasionally  attain  such  a  size 
or  become  so  numerous  as  completely  to  fill  the  cavity. 
Cysts  are  also  quite  frequently  produced.  Before  the  days 
of  rational  nasal  therapeutics  these  cysts  would  assume 
such  dimensions  that  they  finally  caused  the  anterior  or 
inferior  wall  to  soften  and  bulge,  and  this  condition  was 
known  as  "  hydrops  of  the  antrum  of  Highmore."  The 
bulging  wall  of  bone,  under  certain  circumstances,  becomes 
greatly  attenuated  and  transmits  to  the  paljmting  finger  a 
feeling  like  the  crackling  of  parchment.  This  condition 
may  be  confounded  with  true  maxillary  cysts,  usually  of 
dental  origin,  and  the  error  cannot  always  be  avoided  be- 
fore operation,  when  the  true  condition  of  affairs  will  be 
revealed. 

Destructive  changes  are  also  observed  in  the  inner  mem- 
brane as  the  result  of  protracted  suppuration.  Ulcers  of 
the  mucous  membrane  and  of  the  bone,  and  even  complete 
necrosis  of  portions  of  the  wall,  are  sometimes  found  when 
the  cavity  is  opened. 

The  diagnosis  of  catarrh  of  the  antrum  of  Highmore 
rests,  in  the  first  place,  on  the  presence  of  abnormal  secre- 
tion. Its  possibility  must  be  borne  in  mind  whenever 
mucus  or  other  similar  material  is  found  on  the  floor  of 


FOCAL  DISEASES.  99 

the  nose.  The  presence  of  such  matters  in  the  middle 
meatus,  especially  if  they  are  purulent,  is  extremely  sus- 
picious. If  pus  coutinues  to  be  poured  out  after  the  sjK)t 
has  been  carefully  cleansed,  suspicion  is  practically  con- 
verted into  a  certainty.  The  only  other  cavities  that 
empty  in  this  region  are  the  frontal  sinus  and  a  few  of 
the  median  ethmoid  cells.  The  mouth  of  the  former  lies 
more  anteriorly  ;  that  of  the  latter,  nearer  the  median  line. 
Absolute  certainty  is  secured  by  performing  an  explora- 
tory puncture,  followed  by  insufflation  or  irrigation  (see 
p.  37).  If  the  secretion  is  scanty,  a  preliminary  packing 
for  the  purpose  of  allowing  the  secretion  to  accumulate  is 
indicated  (p.  38).  A  pledget  of  cotton  of  suitable  size  is 
thrust  as  far  back  as  possible  into  the  middle  meatus, 
and,  if  the  frontal  sinus  as  a  possible  source  of  the  secre- 
tion is  to  be  excluded,  a  second  pledget  is  applied  in  front 
of  the  hiatus  semilunaris.  The  distribution  of  the  accu- 
mulated secretion  on  the  tampon  sometimes  suffices  to 
indicate  its  origin,  but  in  any  case  exploratory  puncture  • 
may  be  expected  to  yield  positive  information.  In  sus- 
picious cases  a  negative  result  from  exploratory  puncture 
is  not  sufficient,  for  the  cavity  may  continue  to  secrete, 
and  yet,  owing  to  the  presence  of  free  drainage,  it  may 
contain  little  or  no  secretion.  •  In  two  or  three  cases  the 
author  has  been  obliged  to  repeat  exploratory  puncture 
after  a  somewhat  doubttul  result,  in  order  to  obtain  a 
clear  conception  of  the  state  of  affiiirs. 

It  is  exceptional  that  the  cavity  is  so  full  that  the  with- 
drawal of  the  stilet  from  the  trocar  is  immediately  fol- 
lowed bv  a  flow  of  pus.  On  the  other  hand,  it  sometimes 
happens'  that  a  light  or  amber-colored  serous  exudate 
escapes  in  this  wav,  drop  by  drop,  or  in  somewhat  larger 
quantities,  especially  after  insufflation  through  the  trocar. 
Such  an  event  points  positively  to  the  existence  of  cysts 
in  the  cavity,  and  accordingly  adds  to  the  gravity  of  the 
prognosis  as  regards  recovery. 

It  is,  however,  to  be  remarked  that  this  drastic  pro- 
cedure is  necessary  only  when  the  subjective  symptoms 


100       SPECIAL  PATHOLOGY  AND   TREATMENT. 

are  intense.  In  a  great  number  of  doubtful  cases  the 
procedure  may  be  quite  safely  neglected,  even  if  the  diag- 
nosis is  not  absolutely  assured,  because  both  the  amount 
of  trouble  on  the  part  of  the  physician  and  the  discomfort 
to  the  patient  are  out  of  all  proportion  to  the  gravity  of 
the  disease,  nor,  as  a  matter  of  course,  will  the  question 
of  operative  interference  have  to  be  considered  in  such 
cases.  It  may,  however,  be  remarked  that  the  great 
frequency  of  inflammation  of  the  antrum  of  Highmore, 
which  naturally  follows  from  the  anatomic  position  of 
the  cavities,  rendering  them  liable  to  infection  by  the 
extension  of  a  process  from  the  inferior  turbinate  and 
favoring  the  isolation  of  the  morbid  process  within  them 
by  the  swelling  of  the  surrounding  tissues  and  by  the 
high  position  of  the  orifice  above  the  floor  of  the  cavity, 
is  enhanced  by  the  proximity  of  organs  like  the  teeth  that 
are  so  exceedingly  prone  to  become  diseased.  The  open- 
ings of  the  other  accessory  sinuses  lie  approximately  at 
■the  lowest  point  of  the  cavity.  Accordingly,  infection  of 
the  antrum  of  Highmore,  derived  from  the  diseased  pulp 
by  way  of  the  lymph-channels,  and  catarrhal  conditions 
due  to  the  irritation  accompanying  coronal  caries,  are  quite 
common,  and,  inversely,  catarrh  of  the  antrum  may  give 
rise  to  periodontitis  at  theToot  of  a  tooth,  and  thus  estab- 
lishes a  vicious  circle,  so  that  the  antrum  disease  persists 
even  after  other  causes  have  been  removed. 

In  all  such  cases  the  first  thing  to  be  done  is  to  extract 
the  suspicious  tooth  or  teeth,  nor  should  it  be  delayed  until 
the  diagnosis  has  been  confirmed  by  an  exploratory  punc- 
ture. In  this  way  the  author  has  seen  many  an  obstinate 
catarrh  of  the  cavity  subside  in  a  short  time  witliout 
direct  treatment.  The  conditions  are  different,  however, 
in  all  purulent  forms  of  antrum  disease,  and,  in  fact,  in 
all  conditions  accompanied  by  marked  subjective  symp- 
toms. 

The  alveoli  of  the  second  bicuspid  and  first  molar  teeth 
are  immediately  contiguous  to  the  floor  of  the  antrum 
(see  Fig.  3),  while  the  cavity  cannot  be  reached  at  all  or 


FOCAL  DISEASES. 


101 


only  with  great  difficulty  by  way  of  the  first  bicuspid  or 
the  second  molar.  If  one  of  these  teeth  is  diseased  or 
lost,  the  cavity  can  be  entered  through  its  alveolus.     By 


Fig.  14. 


means  of  the  instrument  here  depicted  (Fig.  14),  which 
has  an  oblique  cutting-edge,  the  intervening  layer  of  bone 
can  be  perforated  with  great  ease.     The  opening  should 


.11  cm •« 


Fig.  15.— Irrigating  cannula  for  the  sphenoid  sinus. 

be  packed  with  iodoform  gauze  -for  a  day  or  two,  and  after 
that  requires  no  further  treatment.  Through  the  opening 
a  cannula  (Fig.  16)  is  introduced,  which  is  attached  by 


b  cm— 


Fig.  16.— Irrigating  cannula  for  the  antrum  of  Highmore. 

its  anterior  extremity  to  a  rubber  tube  communicating 
with  a  bulb.  With  this  instrument  the  patient  is  directed 
to  inject  a  lukewarm  aseptic  alcoholic  solution  two  or 
three  times  a  day. 


102       SPECIAL  PATHOLOGY  AND  TREATMENT. 

This  mild  procedure  will  be  successful  only  when 
the  normal  cavity  has  not  undergone  extensive  alter- 
ations. If  there  is  reason  to  believe  that  such 
alterations  have  taken  place,  as  in  the  case  of 
purulent  catarrh  without  disease  of  the  teeth, 
polypus  formation  in  the  nose  or  after  a  long- 
continued  mucopurulent  secretion,  or  if  cysts  or 
the  presence  of  polypi  are  directly  discovered,  or 
if,  finally,  irrigation  through  the  alveolus  pro- 
duces no  improvement  after  two  or  three  weeks, 
the  cavity  must  be  laid  open.  This  operation  re- 
quires a  general  anesthetic. 

The  trunk  should  be  slightly  elevated.  After 
the  gums  have  been  painted  with  a  10  per  cent, 
solution  of  cocain  a  large  plug  is  pushed  be- 
tween the  teeth  and  the  cheeks,  behind  the  field 
of  operation,  which  is  finally  cleared  for  action 
by  means  of  the  mouth-gag  (Fig.  4,  p.  32). 

When  the  patient  is  completely 
anesthetized,  the  fold  of  mucous 
membrane  produced  above  the  sec- 
ond bicuspid  by  drawing  the  upper 
lip  upward  is  divided  with  the  scis- 
sors along  with  the  periosteum,  and 
the  latter  is  pushed  backward  and 
upward  with  an  elevator,  after  which 
a  double  retractor  with  very  long 
hooks  (Fig.  17) .  is  inserted.  The 
unusual  length  of  the  hooks  is  ne- 
cessary to  include  the  thick  upper 
lip.  The  anterior  wall  of  the  cav- 
FiG.  17.  ity  is  now  laid  bare  by  means  of  a     ^^^- 18. 

chisel  with  an  oblique  cutting-edge 
(Fig.  18),  which  readily  penetrates  the  bone.  A  quad- 
rangular piece  is  chiseled  out  of  the  wall,  the  chisel 
being  successively  removed  and  reapplied,  and  the 
excised  section  of  bone  is  then  removed  with  a  sharp 
forceps.      No    great    harm    is   done   if,   as   often    hap- 


FOCAL  DISEASES.  103 

pens,  the  section  of  bone  falls  into  the  cavity,  as  it 
will  be  brought  out  later  with  the  packing,  or,  if 
necessary,  can  be  extracted  under  direct  illumination. 
After  packing  the  cavity  for  a  short  time  to  control 
hemorrhage,  an  attempt  is  made  to  obtain  a  view  of 
the  interior,  or,  if  tliat  is  impossible,  to  determine  the 
nature  of  its  contents  by  means  of  a  probe.  Polypi 
or  granulations  are  removed  with  a  snare,  a  forceps,  or 
a  sharp  spoon.  Disintegrated  mucous  membrane  and 
exposed  carious  portions  of  bone,  which  are  frequently 
found  at  the  inner  lower  wall,  are  then  curetted  away. 
The  entire  cavity  is  then  rapidly  packed  with  narrow 
strips  of  iodoform  gauze  from  1  to  1.5  meters  in  length, 
filling  the  entire  space  as  far  as  the  opening  in  the  bone. 
The  flap  of  periosteum  and  mucous  membrane  is  then 
released  from  the  retractor  and  freed  by  means  of  two 
vertical  incisions  running  upward  from  each  angle  of  the 
wound,  rendering  the  flap  freely  movable  from  side  to 
side.  It  is  then  fixed  to  the  upper  margin  of  the  bone  by 
means  of  another  tampon  consisting  of  a  short  strip  of 
nosophen  gauze,  and  a  third  thin  strip  of  gauze  is  lightly 
packed  into  the  pocket  formed  by  the  mucous  membrane 
in  the  posterior  angle  of  the  wound.  After  two  or  three 
days  the  first  packing,  that  which  was  introduced  into  the 
cavity,  is  removed  altogether.  The  external  strips  of 
gauze  may,  if  necessary,  be  changed  earlier,  at  which  time 
the  interior  of  the  cavity  is  inspected  with  a  head-mirror 
so  as  to  remove  any  foreign  material  remaining,  such  as 
polypi,  splinters  of  bones,  and  the  like.  After  the  flap 
of  mucous  membrane  has  become  adherent  at  the  upper 
edge  of  the  opening  the  subsequent  treatment,  consisting 
in  irrigation  performed  two  or  three  times  a  day,  as  de- 
scribed above,  may  be  intrusted  to  the  patient.  In  the 
author's  experience  the  duration  is  not  in  the  least  aifected 
by  any  internal  medication,  even  in  the  most  protracted 
cases.  In  the  severest  cases,  with  complete  degeneration 
of  the  mucous  membrane,  full  recovery  cannot,  as  a  rule, 
be  expected  until  the  volume  of  the  cavity  has  been  re- 


104        SPECIAL  PATHOLOGY  AND  TREATMENT. 

diiced  to  its  minimum  ;  while  in  milder  cases,  especially 
when  the  discharge  consists  simply  of"  fetid  pus,  the  sup- 
puration ceases  sometimes  in  one  or  two  weeks,  or  at  least 
in  from  one  to  three  months. 

Radical  operation  is  indicated  only  when  the  orifice 
is  situated  so  high  that  the  irrigating  fluid  cannot  return, 
or  when  extensive  destruction  of  the  bone  has  taken  place. 
In  this  operation  a  wide  opening  is  made  in  the  anterior 
wall  of  the  cavity,  and,  in  addition,  the  inner  wall,  whicli 
communicates  with  the  nose,  is  chiseled  away.  The  nasal 
mucous  membrane  is  then  reflected  into  this  opening  so 
that  a  permanent  broad  communication  is  established  be- 
tween the  antrum  and  the  inferior  meatus  of  the  nose. 
The  packing  is  then  introduced  through  the  nose  and 
allowed  to  remain  in  place  until  the  mucous  membrane 
flap  has  become  adherent. 

DISEASES  OF  THE  ETHMOID  CELLS. 

Disease  of  the  ethmoid  cells  occurs  usually  in  the  course 
of  some  general  infection,  most  frequently  influenza.  The 
secretion  is  practically  always  purulent,  because  it  requires 
a  high  degree  of  inflammation  to  overcome  the  natural 
tendency  to  recovery  which  is  afforded  by  the  favorable 
anatomic  conditions,  the  orifices  of  the  cells  being  wide 
and  situated  at  the  lowest  point  of  the  cavities.  For  pus 
to  accumulate,  the  tissues  about  the  orifice  must  become 
swollen  or  the  mucous  membrane  must  undergo  prolifer- 
ation. In  the  acute  Stagfe  normal  drainage  may  be 
anticipated  by  cautious  probing  of  the  middle  or  superior 
nasal  meatus,  but  it  is  not  justifiable  to  attempt  to  effect 
an  entrance  into  the  cells  themselves. 

Chronic  suppuration  is  usually  accompanied  by 
violent  subjective  symptoms  which  become  aggravated 
when  the  secretion  is  dammed  up,  so  that  painless  inter- 
vals generally  coincide  with  profuse  discharge.  The 
secretion  may  be  quite  copious,  but,  as  a  rule,  it  is 
moderate  only  in  quantity.     In  many  cases  the  lacrimal 


FOCAL  DISEASES.  105 

bone  is  sensitive  to  pressure.  Not  so  very  rarely  the 
relatively  small  and  hidden  openings  become  closed,  the 
secretion  accumulates,  and  a  true  (closed)  empyema  de- 
velops. The  delicate  walls  of  bone  suffer  distention  and 
soon  break  down,  forming  a  large  cavity.  If  this  cavity 
extends  toward  the  exterior,  a  bulging  is  produced  at  the 
inner  canthus  of  the  eye,  and  the  globe  is  displaced  out- 
ward ;  occasionally  an  orbital  abscess  develops. 

Small  circumscribed  collections  of  mucus  are  known 
as  bone  cysts ;  they  are  cyst-like  dilatations  with  thin 
bony  walls  in  the  middle  turbinate,  and  contain  either 
pus  or  a  thick,  tenacious  mucus  suggesting  polypous  mate- 
rial. In  the  latter  case  it  is  justifiable  to  assume  that  a 
mucous  cyst  has  gradually  enlarged  to  the  point  of  com- 
pletely filling  the  cavity  and  distending  the  bones,  for  in 
these  sinuses  also  cysts  and  small  polypi  of  the  mucous 
membrane  are  quite  common.  Indeed,  the  extraordinary 
high  })ercentage  of  ethmoid  suppurations  accompanied  by 
intranasal  polypi  makes  it  probable  that  the  great  number 
of  small  intracellular  tumors  of  this  kind  escape  obser- 
vation. Suppuration  of  the  ethmoid  cells  as  an  isolated 
affection  is  not  very  common  ;  it  is  much  more  often  a 
concomitant  of  inflammations  in  the  antrum  or  frontal 
sinus;  hence  the  differential  diagnosis  is  apt  to  be  difficult. 

The  nasal  picture  in  severe  cases  is  fairly  character- 
istic, consisting  chiefly  of  alteration  in  the  outline  of  the 
middle  turbinate,  which  in  a  sense  is  a  mere  appendix  of 
the  labyrinth.  The  anterior  extremity  is  converted  into 
an  irregular  mass  by  the  thickening  of.  the  mucous  mem- 
brane and  the  enlargement  of  the  bone ;  later  it  may  pre- 
sent fragmentation,  or  the  extremity  may  be  brittle  and 
in  places  deficient  if  the  bone  becomes  softened  or  carious. 
Occasionally  the  bone  presents  a  hideous  aspect  from  the 
presence  of  large  and  small  pol5'pi,  a  quantity  of  oozing 
pus,  and  extensive  areas  of  granular  mucous  membrane. 
Cleavage  of  the  turbinate,  producing  a  bifid  effect  in  the 
anterior  extremity,  has  also  been  observed. 

The   diagnosis   is   made    partly   by   the   characteristic 


106        SPECIAL  PATHOLOGY  AND  TREATMENT. 

appearance  of  the  general  picture  and  partly  by  the  re- 
sults of  probing,  by  which  it  is  determined  wiiether  the 
pus  emanates  from  bone  cavities  at  the  upper  portion  of 
the  middle  turbinate,  and,  if  so,  from  which  of  these 
cavities.  The  anterior  and  median  cells  empty  into  the 
middle  meatus,  and  are,  therefore,  explored  through  this 
structure ;  the  posterior  cells  are  reached  through  the 
upper  meatus — tiiat  is  to  say,  by  introducing  the  probe  to 
the  median  side  of  the  middle  turbinate.  Abnormal  com- 
munications may,  however,  be  established  by  perforation 
of  the  thin  bony  walls. 

As  the  antrum  and  the  frontal  sinus  also  empty  in  the 
middle  meatus,  the  presence  of  suppuration  from  one  of 
these  cavities  must  first  be  excluded,  or,  if  such  a  condi- 
tion is  present,  the  cavities  must  first  be  evacuated  to 
guard  against  error  in  diagnosis — that  is  to  say,  in  the 
case  of  the  antrum  exploratory  puncture  followed  by  irri- 
gation, and  in  the  case  of  the  frontal  sinus  irrigation 
through  the  frontal  orifice,  must  be  performed.  It  is  true 
that  this  is  easier  in  theory  than  in  practice,  particularly 
in  the  case  of  the  frontal  sinus,  which  it  is  often  impos- 
sible to  keep  free  from  secretion  without  an  operation, 
and,  on  the  other  hand,  the  most  anterior  of  the  ethmoid 
cells,  owing  to  its  high  position  and  great  size,  is  very  apt 
to  be  mistaken  for  the  frontal  sinus.  But  as  in  such  a 
case  both  cavities  are  practically  always  involved,  the 
failure  to  establish  an  accurate  diagnosis  does  no  practical 
harm.  On  the  contrary,  one  is  more  apt  to  err  in  the 
direction  of  too  accurate  localization,  since  enlargement 
of  the  middle  turbinate  stands  in  the  way  of  recovery  in 
the  case  of  any  disease  of  an  accessory  cavity,  whether  it 
be  contiguous  to  the  middle  turbinate  or  not. 

Suppuration  in  the  posterior  cells  may  easily  be  mis- 
taken for  inflammation  of  the  sphenoid  sinus.  Although 
the  latter  cavity  can  be  identified  by  means  of  the  probe 
without  any  special  difficulty,  the  middle  turbinate  may 
be  in  such  close  contact  with  the  septum  as  to  make  it 
absolutely   impossible  to  determine  by  inspection  from 


FOCAL  DISEASES. 


107 


which  of  these  two  cavities  the  pus  is  coming.  In  such 
a  case,  and  in  fact  in  all  doubtful  cases,  amputation  of  the 
anterior  extremity  or  of  the  entire  middle  turbinate  should 
be  performed  (see  p.  51),  the  more  imhesitatingly  as  the 
operation  is  equally  necessary  from  a  therapeutic  point 


of  view.  Both  the  ethmoid  cells  and  the  orifice  of  the 
sphenoid  sinus  are  then  freely  exposed  to  view  (Plate 
28,  Fig.  4). 

In  addition  to  the  exposure  of  these  structures,  removal 
of  the  anterior  and  inferior  walls  of  the  diseased  cells  is 
required  so  as  to  preclude  the 
possibility  of  pus-retention. 
The  best  instruments  for  this 
purpose  are  bone-forceps  that 
cut  from  before  backward  like 
the  instrument  illustrated  in 


/i-».    /r* 


Fig.  20. 


Fig.  19,  and  the  sharp  spoon. 
In  almost  every  case  this 
intranasal  operation  will  be 
found  sufficient ;  if  the  con- 
ditions are  unusually  difficult, 
the  following  external  opera- 
tion will  become  necessary. 

A  curved  incision  is  car- 
ried immediately  below  and 
parallel  with  the  eyebrow, 
beginning  about  the  middle 

of  its  course  and  extending  to  the  root  of  the  nose.  From 
this  point  the  incision  is  continued  downward  to  the  dis- 
tance of  half  the  length  of  the  nasal  bone,  and  terminated 
at  the  inner  canthus  of  the  eye  (Fig.  20).     The  vertical 


108       SPECIAL  PATHOLOGY  AND  TREATMENT. 

portion  of  the  incision,  wliich  slioiild  divide  both  skin  and 
periosteum,  corresponds  exactly  with  the  nasal  boundary 
of  the  orbit.  In  dividing  the  })eriosteum  the  supra-orbital 
nerve  (w.  «.),  which  runs  underneath  the  periosteum 
within  the  orbit,  should  be  avoided.  After  it  has  been 
exposed  it  may  be  necessary  to  thrust  it  aside  so  as  to 
guard  against  its  being  injured  later  on  in  the  o]>eration. 
To  do  this  the  bridge  of  bone  forming  the  upper  boundary 
of  the  supra-orbital  foramen  (/.  s.),  is  carefully  chiseled 
through,  or,  if  the  supra-orbital  notch  is  not  bridged  over, 
the  covering  strand  of  connective  tissue  is  divided,  where- 
upon the  nerve  can  readily  be  pushed  aside  after  the  peri- 
osteum has  been  stripped  back.  The  entire  flap,  including 
the  periosteum,  is  then  reflected  downward  with  an  elevator. 
As  the  only  vessels  divided  by  the  incision  are  the  cuta- 
neous vessels,  the  operation  is  practically  bloodless,  and 
a  large  portion  of  the  inner  wall  of  the  orbit  will  be  ex- 
posed {Ip.,  lamina  papyracea ;  L,  reflected  flap).  The 
most  accessible  structure  is  the  lacrimal  bone  (/).  This 
is  chiseled  through  in  a  direction  inward  and  downward 
or  backward,  and  the  labyrinth  of  the  ethmoid  is  thus 
reached.  The  illustration  shows  portions  of  the  bone  that 
are  not  exposed  by  the  incision.  These  are  the  ascending 
nasal  process  of  the  superior  maxilla  (p.  n.),  the  suture 
between  this  and  the  nasal  bone,  and  the  suture  between 
these  two  bones  and  the  nasal  process  of  the  frontal  bone. 
They  have  been  dissected  out  partly  to  make  the  ana- 
tomic relations  clearer  and  partly  to  show  that  the 
frontal  sinus  can  also  be  reached  by  means  of  this  incision. 

There  is  no  danger  whatever  of  injuring  the  lacrimal 
organs  in  this  operation. 

If  the  frontal  sinus  is  also  involved,  the  operation  may 
be  performed  immediately  after  the  frontal  sinus  has  been 
opened. 

It  may  be  worth  mentioning  that  suppurations  of  the 
ethmoid  cells  occur  symptomatically  after  diseases  affect- 
ing neighboring  structures.  Thus  the  ethmoid  cells  may 
represent  the  outlet  of  an  orbital  abscess,  or  of  suppuration 


FOCAL  DISEASES.  109 

of  the  frontal  sinus,  of  empyema  of  the  sphenoid  sinus,  or 
of  abscesses  in  the  frontal  or  even  in  the  temporal  lobe, 
the  latter  of  otitic  origin.  It  follows,  therefore,  that  any 
disease  occurring  in  this  region  requires  careful  super- 
vision and  accurate  weighing  of  the  symptoms. 


DISEASES  OF  THE  SPHENOID  SINUS. 

In  the  sphenoid  sinus  the  conditions  are  much  more 
simple.  Normally,  this  cavity  possesses  a  single  opening, 
situated  between  the  middle  or  superior  turbinate  and  the 
sej)tum.  Large  as  this  cavity  appears  in  the  skeleton,  it 
may  be  very  small  in  the  living  subject,  because  the  deli- 
cate lining  membrane  covers  iu  the  greater  portion  of  the 
anterior  boundary  where  the  bone  is  deficient  and,  unfor- 
tunately, the  lower  part  more  than  the  upper.  Accord- 
ingly, inflammatory  swelling  of  the  mucous  membrane 
facilitates  retention  of  the  secretions. 

Acute  inflammatiotL  of  the  sphenoid  sinus  is  prob- 
ably more  frequent  than  is  generally  supposed,  being 
masked  by  the  picture  of  violent  coryza  with  severe  head- 
ache, or  perhaps  delirium  and  vertigo.  The  condition 
tends  to  spontaneous  recovery,  and  requires  surgical  inter- 
vention by  probing  the  orifice  only  in  extreme  cases. 

If,  however,  a  chronic  catarrh  or  suppuration 
develops,  the  prognosis  is  more  grave,  chiefly  on  account 
of  the  greater  anatomic  alterations.  The  usual  hyper- 
trophic and  atrophic  changes  that  aifect  the  lining  mem- 
branes are  observed  also  in  this  sinus,  while  caries  and 
perforations  are  not  so  very  rare.  As  the  pus  is  apt  to 
be  scanty,  it  tends  to  become  inspissated,  and  is,  therefore, 
frequently  seen  in  the  form  of  crusts,  especially  at  the 
posterior  border  of  the  vomer,  the  posterior  surface  of  the 
soft  palate,  and  the  posterior  regions  of  the  floor  of  the 
nose  (Plate  22,  Fig.  2).  It  may,  how^ever,  flow  down 
along  the  median  surface  of  the  middle  turbinate  and 
make  its  appearance  at  the  septum.  Since  suppuration  in 
the  sphenoid  sinus  in  the  majority  of  instances  is  asso- 


110        SPECIAL  PATHOLOGY  AND  TREATMENT. 

ciated  with  a  similar  process  in  other  accessory  cavities, 
especially  the  ethinoid  colls,  the  secretion  alone  cannot 
be  utilized  in  the  diagnosis.  Pus  must  be  demonstrated 
within  the  cavity  itself,  because  a  secretion  appearing  at 
the  same  point  may  be  derived  from  the  posterior  ethmoid 
cells,  or  the  spheno-ethraoid  recess  (see  Fig.  2,  p.  10). 

The  symptoms  of  suppuration  of  the  sphenoid  sinus  do 
not,  on  the  whole,  differ  greatly  from  those  observed  in 
similar  disease  of  other  cavities.  Severe  headache  may 
or  may  not  be  present ;  vertex  headache  and  vertigo  are 
more  or  less  suspicious.  In  the  severest  cases  irritative 
symptoms  in  the  domain  of  the  sphenopalatine  ganglion 
and  in  the  distribution  of  the  optic  nerve,  including  optic 
neuritis  and  atrophy,  have  occurred.  A  thickening  of 
the  upper  portion  of  the  septum  should  direct  the  atten- 
tion to  the  sphenoid  sinus.  This  is  practically  the  only 
intranasal  secondary  phenomenon  that  is  observed.  It 
follows  that  the  diagnosis  must  be  based  chiefly  on  direct 
examination  of  the  sinus. 

The  cavity  may  be  identified  with  the  aid  of  a  sound 
introduced  along  the  septum  opposite  the  middle  turbinate. 
In  this  direction  the  posterior  wall  of  the  cavity  lies  at 
an  average  distance  of  8.2  cm.  in  men,  and  7.6  cm.  in 
women,  from  the  line  of  jimction  between  the  septum  and 
the  upper  lip.  As  the  entrance  to  the  cavity  is  usually 
placed  a  little  to  one  side  of  the  median  line,  the  probe 
should  be  bent  slightly  outward  at  a  short  distance  from 
its  upper  extremity.  The  fact  that  the  probe  has  entered 
the  cavity  is  definitely  determined  by  the  instrument 
catching  when  it  is  depressed.  If  it  had  entered  the 
recess,  it  would  glide  downward  in  an  oblique  direction. 
So  far  all  that  has  been  learned  is  that  the  probe  is  within 
the  cavity,  and  unless  the  instrument  at  once  comes  upon 
rough  or  exposed  bone,  determined  by  the  ringing  sound 
which  is  produced,  or  a  distinct  thickening  of  the  mucous 
membrane  can  be  made  out,  it  will  be  necessary  to  demon- 
strate the  presence  of  secretion  within  the  cavity.  Some- 
times the  secretion  flows  along  the  probe  so  as  to  be 


FOCAL  DISEASES.  HI 

directly  seen;  if  not,  a  cannula  (Fig.  15,  p.  101)  must  be 
introduced  and  the  cavity  irrigated  while  the  patient 
bends  the  head  well  over.  If  secretion  is  present,  it  will 
be  directly  evacuated  by  this  procedure. 

The  treatment  of  chronic  inflammation  of  the  sphenoid 
sinus  should  include  more  radical  measures  than  mere 
irrigation.  The  only  hope  of  success  lies  in  thoroughly 
exposing  the  cavity  by  removing  the  anterior  wall,  and, 
if  possible,  the  floor  of  the  cavity.  In  attacking  the  floor 
there  is  no  danger  of  doing  any  injury,  and  the  bone  may 
be  confidently  scraped  away  with  a  small,  sharp  spoon 
(Fig.  13,  b,  p.  52)  or  clipped  away  with  bone-forceps 
(Fig.   21).     It  goes  without  saying  that  if  the  middle 


Fig.  21. — Bone-forceps. 

meatus  is  much  in  the  way,  it  must  first  be  removed  ; 
but  in  a  good  many  cases  this  preliminary  operation  is 
unnecessary.  To  expose  the  cavity  from  without  through 
the  labyrinth  of  the  ethmoid  is  absolutely  unnecessary, 
since  it  can  be  made  sufficiently  accessible  through  the 
nose  without  inflicting  the  same  amount  of  damage  (Plate 
28,  Fig.  4). 

DISEASES  OF  THE  FRONTAL  SINUS. 

Although  the  practising  physician  frequently  thinks  of 
suppuration  from  the  frontal  sinus,  the  condition, 
as  a  matter  of  fact,  is  extremely  rare,  and  frontal  head- 
ache is  as  common  as  it  is  diagnostically  unimportant  in 
suppurations  from  the  nose.  The  cavity  has  a  broad  and 
deep  outlet,  and  is,  therefore,  little  prone  to  become  dis- 
eased, but,  on  the  other  hand,  spontaneous  recovery  is 
little  likely  to  take  place,  as  the  sinus  frequently  has  a 


112       SPECIAL  PATHOLOGY  AND  TREATMENT. 

number  of  deep  recesses  which  extend  below  the  level  of 
the  internal  orifice,  and  when  the  outlet  has  once  become 
obstructed,  the  obstruction  is  with  difficulty  removed. 
Besides,  the  frontal  sinus,  even  more  than  the  sphenoid 
sinus  and  the  antrum  of  Highmore,  represents  the  proto- 
type of  a  "  rigid  cavity,"  the  great  resistance  of  which  to 
mild  therapeutic  measures  every  surgeon  knows  to  his 
cost.  It  is  significant  of  the  resistance  ("  Beharrungs- 
vermogen")  of  these  cavities  that  free  communications 
have  been  found  between  a  suppurating  cavity  and  an 
adjacent  healthy  cavity  in  the  form  of  congenital  defects 
in  the  separating  wall,  and  that  in  most  cases  only  one 
cavity  is  found  diseased. 

Usually,  not  to  say  invariably,  suppuration  of  the 
frontal  sinus  is  complicated  by  suppuration  of  other  cav- 
ities in  the  ethmoid  bone  and  in  the  upper  maxilla.  The 
anterior  portion  of  the  labyrinth  may,  indeed,  be  said  to 
constitute  a  kind  of  vestibule  for  these  cavities,  and  the 
infundibulum  frequently  opens  freely  in  the  direction  of 
the  maxillary  orifice,  so  that  the  pus  in  such  cases  directly 
enters  the  antrum.  But  the  principal  reason  probably  is 
that  an  infection  severe  enough  to  overcome  the  resist- 
ance of  the  frontal  sinus  finds  no  difficulty  in  attacking 
the  remaining  sinuses,  which  are  much  less  resistant  to 
disease. 

It  is  easier  to  exclude  the  existence  of  suppuration  in 
this  region  than  to  establish  its  presence.  The  former 
can  be  done  with  certainty  if  the  anterior  cleft  of  the  nose 
— that  is,  the  space  between  the  septum,  the  anterior  ex- 
tremity of  the  middle  turbinate,  and  the  outer  wall  of 
the  nose,  represented  by  the  nasal  process  of  the  upper 
maxilla — immediately  comes  into  view  posteriorly  when 
the  middle  meatus  has  been  dammed  up.  It  becomes 
positively  easy  if  the  orifice  of  the  frontal  meatus  can 
be  directly  seen.  Unfortunately,  the  discovery  of  pus 
deposited  at  or  flowing  down  toward  this  point  may  be 
derived  from  the  anterior  ethmoid  cells  or  even  from 
regions  situated  still  further  back,  such  as  the  antrum  of 


FOCAL  DISEASES.  113 

Highmore,  if  the  middle  turbinate  is  in  close  apposition 
to  the  septum  in  such  a  way  as  to  form  a  capillary  space 
through  which  the  pus  rises  to  the  surface. 

Absolutely  characteristic  sjrmptoms  are  rarely  present. 
Personally,  the  author  has  often  observed  occipital  head- 
ache in  this  very  condition.  Sensitiveness  to  pressure 
about  the  supra-orbital  foramen  may  be  present  also  in 
antrum  disease,  and  pain  elicited  by  pressure  or  percussion 
of  the  anterior  wall  of  the  cavity  occurs  only  in  extreme 
cases.  Owing  to  the  extraordinary  diversity  of  the  ana- 
tomic relations,  the  variations  in  the  thickness  of  the 
boundary  walls,  which  range  from  the  thickness  of  paper 
to  nearly  1  cm.,  and  the  variations  in  the  size  of  the  cav- 
ities from  that  of  a  walnut  down  to  complete  obliteration, 
transillumination  is  absolutely  useless.  Hence  the  diag- 
nosis, when  the  suspicion  has  once  been  aroused  by  the 
constant  collection  of  pus  in  the  most  anterior  portions  of 
the  nose,  must  be  determined  ultimately  by  the  direct 
demonstration  of  secretion  within  the  cavity.  As  has 
been  said,  the  cavity  is  identified  with  the  aid  of  the 
probe.  At  a  point  3  to  4  cm.  from  its  anterior  extremity 
the  probe  is  bent  over  to  form  a  quadrant  of  a  circle, 
and  introduced  into  the  previously  cocainized  infundib- 
ulum  or  through  the  frontal  orifice,  if  it  is  visible,  and 
gently  pushed  upward  and  forward.  By  this  method  the 
cavity  may  possibly  be  reached  in  about  one-third  of  tlie 
cases,  depending  on  the  length  of  the  portion  introduced 
in  relation  to  the  external  measurements.  It  is  not,  by 
any  means,  impossible  for  the  probe  to  deviate  into  the 
ethmoid  bulla  (largest  ethmoid  cell).  In  doubtful  cases 
the  position  of  the  probe  may  be  accurately  determined 
by  means  of  Rontgen-ray  illumination.  If,  after  the 
probe  has  been  introduced,  pus  is  seen  to  flow  down  along 
its  side,  the  diagnosis  is  assured.  If  it  is  impossible  to 
effect  an  entrance,  a  frontal  sinus  cannula  (Fig.  22)  is 
introduced  into  the  infundibulum  or  into  the  ostium,  and 
air  insufflated  under  illumination.  If  any  secretion  is 
present,  it  will  be  brought  to  light  by  this  procedure. 


114       SPECIAL  PATHOLOGY  AND  TREATMENT. 

To  make  sure  that  the  secretion  cemes  from  the  sinus,  a 
cold  1  per  cent,  solution  of  carbolic  acid  may  be  injected. 
If  the  patient  is  positive  that  he  feels  this  solution  above 
the  eyebrows,  the  operator  may  be  sure  that  he  has 
reached  the  cavity. 

Another  diagnostic  aid,  especially  useful  in  excluding 
an  accompanying  suppuration  from  the  antrum,  is  found 
in  observing  that  after  the  middle  meatus  has  been  care- 
fully cleansed  mucus  instead  of  the  pus  that  has  been 
removed  flows  down  from  above.  This  mucus  represents 
a  recent  secretion,  since  the  purulent  character  develops 
only  after  the  secretion  has  remained  within  the  cavity 
for  some  time.  Hence  if  the  ethmoid  bone  has  been 
excluded,  such  secretion  can  come  only  from  the  frontal 
sinus. 

If  the  entrance  to  the  sinus  is  greatly  contracted,  or  if 
the  clinical  picture  is  complicated  by  suppurations  in  other 
accessory  sinuses,  a  positive  diagnosis  per  vias  naturales 
may  be  absolutely  impossible.  If  the  suspicion  based  on 
the  symptoms  is  sufficiently  strong  and  the  patient's  con- 
dition becomes  alarming  enough  to  demand  a  decision,  the 
question  of  exploratory  opening  of  the  cavity  by  means 
of  an  external  incision  may  be  considered.  The  attempt 
to  break  through  the  floor  from  the  nose  and  enter  the 
cavity  in  this  way  cannot  be  too  severely  condemned. 
An  additional  advantage  of  the  external  incision  is  that, 
if  the  results  are  positive,  it  may  be  followed  immediately 
by  operation.     The  operation  is  performed  as  follows : 

A  vertical  incision  is  made  coinciding  exactly  with  the 
fold  in  the  skin  formed  by  the  corrugator  supercilii,  which 
is  very  near  the  median  line.  The  incision  need  not  be 
longer  than  this  fold,  or,  in  other  words,  about  1^  cm.  in 
length.  If  the  skin  is  free  from  wrinkles,  the  incision  may 
be  carried  along  the  upper  border  of  the  eyebrow  and 
parallel  with  it.  After  the  periosteum  has  been  stripped 
back,  the  bone  is  cautiously  chiseled  away  in  the  median 
line  until  the  operator  is  certain  that  he  has  reached 
the  cavity.     The  investing  mucous  membrane   is  more 


FOCAL  DISEASES.  115 

delicate  than  the  dura  mater,  and  can  be  more  readily 
pushed  back,  although  it  also  manifests  pulsation.  With 
the  aid  of  the  probe  the  operator  then  determines  surround- 
ing anatomic  relations,  and  assures  himself  that  the  sinus 
of  the  other  side  has  not  been  opened,  an  accident  that  is 
quite  possible  on  account  of  the  variable  position  of  the 
dividing  wall  between  the  two  cavities.  If  the  probe 
passes  freely  into  the  nose  or  meets  only  with  the  resist- 
ance of  alterations  in  the  soft  parts,  it  will  suffice  to  enlarge 
the  opening  enough  to  permit  palpation  of  all  the  pockets 
of  the  cavity.  Hypertrophied  tissue  and  diseased  portions 
of  bone  are  then  removed  with  a  sharp  spoon  or  with  a 


-7,5  cm » 


Fig.  2?.— Frontal  sinus  cannula. 

bone-forceps.  If  the  hemorrhage  is  marked,  the  outlet  of 
the  cavity  must  be  temporarily  packed  to  prevent  entrance 
of  blood  into  the  air-passages.  This  procedure  will  also 
do  away  with  the  necessity  of  performing  the  operation 
with  the  patient's  head  hanging  over  backward.  The 
entire  cavity  is  then  packed,  and  the  tissues  are  sutured 
together,  leaving  only  space  enough  for  subsequent  thera- 
peutic measures.  The  after-treatment  consists  in  removing 
the  packing  after  three  days  and  irrigating  the  cavity  with 
a  cannula  (Fig.  16,  p.  101)  which  is  introduced  int«  the 
cavity,  but  not  into  the  outlet. 

At  the  end  of  ten  days  the  irrigations  may  be  performed 
by  the  patient,  as  by  that  time  a  fistula  will  have  been 
formed. 

A  boiled  alkaline  solution  is  used  for  the  irrigation,  and 
during  the  procedure  the  small  opening  of  the  fistula  is 
covered  with  cotton  and  a  small  compress  of  silk. 


116        SPECIAL  PATHOLOGY  AND  TREATMENT. 

If  the  outlet  is  too  mueh  contracted,  either  primarily 
or  as  a  result  of  pathologic  ciianges,  or  if  the  condition  of 
the  interior  of  the  cavity  is  such  as  to  make  regeneration 
improbable,  other  procedures  are  indicated.  The  outlet 
toward  the  nose  must  be  artificially  enlarged,  or  else  the 
power  of  the  cavity  to  produce  secretion  must  be  perma- 
nently abolished.  The  first  object  is  attained  by  means 
of  Killian's  method  of  temporary  resection  of  the  nasal 
bone  and  exposure  of  the  outlet  from  in  front,  after  re- 
moval of  the  intervening  infundibular  cells.  Personally, 
I  doubt  that  this  procedure  is  adequate  in  all  cases,  and 
believe  that  sometimes  resection  of  the  uppermost  portion 
of  the  septum  will  be  required  to  obtain  enough  room. 
This  can,  of  course,  be  performed  through  the  same  in- 
cision. 

Other  operative  measures  may  be  considered  according 
to  the  conditions  in  any  individual  case.  Thus  Luc, 
utilizing  the  fact  that  the  cavity  can  be  drained  at  a  dis- 
tant point  by  going  through  the  labyrinth  of  the  ethmoid 
bone,  closes  it  at  once  and  permanently  from  above. 

If  the  inner  wall  is  extensively  involved  or  deep  re- 
cesses are  present,  permanent  obliteration  of  the  cavity 
after  Kuhnt  oifers  the  only  prospect  of  success.  After 
the  eyebrows  have  been  shaved,  an  incision  is  made  run- 
ning from  the  supra-orbital  arch  inward  along  the  line  of 
the  eyebrows ;  the  entire  anterior  wall  of  the  cavity  is 
then  removed  with  the  periosteum  in  such  a  way  as  to 
leave  nothing  but  soft  parts  in  front.  The  mucous  mem- 
brane, including  the  lining  of  the  outlet,  is  completely 
removed  to  the  last  shred,  so  that  granulations  that  spring 
up  from  the  exposed  bone  and  the  periosteum  of  the  flap 
left  by  the  anterior  wall  gradually  fill  the  entire  cavity. 
By  judicious  use  of  packing  the  flap  may  be  thrust  upward 
far  enough  to  prevent  the  formation  of  any  disfiguring 
contraction. 

Mention  has  repeatedly  been  made  of  the  simultaneous 
occurrence  of  inflammation  in  several  cavities.     In  these 


FOCAL  DISEASES.  117 

combined  suppurations  it  is  obviously  difficult  to 
(lifferentiato  the  individual  foci.  The  means  employed  to 
distinguisli  between  the  individual  diseases  have  already 
been  discussed.  The  existence  of  suppuration  from  sev- 
eral cavities  is  not  without  its  influence  on  the  treatment, 
because  there  is  no  doubt  that  higher  cavities  affect  those 
on  a  lower  plane,  both  by  discharging  their  secretions 
into  tliem  and  by  keeping  up  the  swelling  around  their 
orifices,  so  that  the  morbid  process  in  the  former  must  be 
arrested  before  a  cure  can  be  brought  about  in  the  latter. 
Besides,  the  early  recognition  of  disease  in  one  cavity,  by 
enabling  the  surgeon  to  operate  on  both  at  once,  mate- 
rially tends  to  shorten  the  period  of  treatment.  Thus,  if 
the  labyrinth  of  the  ethmoid  is  involved  in  suppuration 
of  the  frontal  sinus,  the  operation  performed  on  the  latter 
should  be  followed  immediately  by  a  temporary  resection 
of  the  nasal  process  after  Killian,  so  as  to  expose  the  cells 
and  clear  out  their  contents.  In  the  same  way,  if  they 
are  involved  in  suppurations  of  the  antrum,  a  broad  open- 
ino-  must  be  made  from  within  the  nose  before  any  effec- 
tive treatment  can  be  applied  to  the  larger  cavity.  If 
the  frontal  sinus  and  the  antrum  are  affected  together,  it 
is  necessary  to  evacuate  the  frontal  sinus  first  to  achieve 
a  cure  in  the  antrum  of  Highmore.  Owing  to  the  great 
variety  of  possible  combinations  and  the  complexity  of  the 
anatomic  relations,  the  individual  therapeutic  measures 
must  be  determined  by  careful  consideration  of  each  case. 

In  case  the  principles  discussed  in  connection  with 
treatment  of  the  various  focal  diseases  should  not  suffice 
to  determine  the  treatment  of  chronic  inflammations,  the 
following  points  may  be  emphasized  : 

In  the  treatment  of  any  chronic  catarrh  the  occurrence 
of  renewed  injuries  must  be  avoided  from  the  outset. 
Hence  the  patient's  mode  of  life  should  be  regulated 
properly.  The  mere  removal  of  chronic  injuries,  such  as 
congestion,  thermic  influences,  or  dust,  often  has  a  magic 
effect.  Removal  to  a  moist  atmosphere  free  from  dust, 
such  as  may  be  found  in  mountainous  regions  or  in  a  mild 


118        SPECIAL  PATHOLOGY  AND  TREATMENT. 

sea-climate,  especially  Venice,  in  the  springtime,  should 
be  advised.  Inhalations  of  brine,  in  themselves  very 
beneficial,  require  great  caution  in  their  application  to 
avoid  the  risk  of  imilateral  cooling. 

In  regard  to  the  local  treatment,  the  cavities  must  be 
kept  free  from  secretions  by  means  of  mouth-washes, 
alkaline  sprays,  irrigations,  and  the  like;  the  condition 
of  the  teeth  must  be  strictly  looked  after,  and  if  stumps 
are  present,  they  must  be  extracted.  The  passages  of  the 
nose  in  all  nasal  diseases  must  be  rendered  permeable  to 
the  air,  both  to  relieve  the  symptoms  and  to  combat  the 
cause  of  the  disease. 

Simple  hyperemia  of  the  turbinates  can  usually  be 
effectively  controlled  by  cauterizing  them  with  trichlor- 
acetic acid.  The  superficial  destruction  brougiit  about  in 
this  way,  while  it  includes  the  superficial  nerve-endings 
which  are  diseased  and  keep  up  a  constant  reflex  irrita- 
tion, avoids  any  injury  to  the  functionating  portions  of 
the  mucous  membrane,  which  are  always  impaired  when 
more  energetic  caustics,  and  especially  cauterization  with 
the  actual  cautery,  are  employed.  It  is  for  this  reason 
that  submucous  cauterization  was  recommended  instead 
of  superficial  cauterization,  in  the  general  portion  of  this 
work,  for  the  purpose  of  destroying  true  hyperplastic 
erectile  tissue  (see  p.  47). 

The  question  of  instrumental  ablation  of  hyperplastic 
or  other  neoplastic  tissue  was  also  discussed  at  that  place 
(p.  48).  The  technic  of  these  things  can  be  learned  only 
by  practice.  One  more  observation  may  here  be  added. 
The  cold  snare,  which  is  completely  withdrawn  into  the 
cannula,  is  sometimes  recommended  for  the  removal  of 
the  hyperplastic  extremity  of  the  inferior  turbinate.  I 
am  led  by  a  number  of  experiences  to  advise  strongly 
against  this  proceeding.  In  many  cases  the  structure  is 
so  tenacious  that  the  cold  snare  fails  to  cut  through  it, 
and  if  traction  is  applied,  the  entire  investment  of  the 
inferior  turbinate  is  torn  away,  which  is  certainly  an 
unjustifiable  mutilation,  not  to  mention  the  unpleasant 


SYMPTOMATIC  PERSISTENT  INFLAMMATIONS.  119 

hemorrhage  that  accompanies  it.  If  the  hot  snare  is  used 
and  caretully  drawn  through  the  bone,  only  the  portion 
caught  within  the  loop  is  removed,  and  the  hemorrhage 
is  quite  insigniticant. 

SYMPTOMATIC  PERSISTENT  INFLAMMA- 
TIONS. 

While  in  the  above-described  chronic  inflammations 
the  anatomic  foundation  of  the  process  presents  many 
variations  in  the  different  stages,  the  histologic  basis  is 
practically  always  the  same.  The  symptomatic  forms 
very  frequently  present  a  great  variety  of  anatomic 
changes  in  combination. 

SYPHILIS. 

Although  syphilis  may  show  a  tendency  to  chronicity 
in  the  secondary-  stage,  the  alterations  must  be  regarded 
as  transitional  forms  approaching  those  of  the  tertiary 
period,  the  usual  foundation  of  which  is  represented  in 
the  diffuse  or  circumscribed  infiltration  known  as  a 
gumma.  It  is  veri'  rarely  that  the  affection  is  observed 
at  this  stage  of  tumor  formation  before  destructive  altera- 
tions have  set  in.  Now  and  again  it  may  be  seen  in  the 
tongue,  where  gummons  infiltrates  may  in  rare  cases  per- 
sist for  weeks  without  materially  increasing  in  size  or 
changing  their  form,  until  finally  ulceration  sets  in  (Plate 
7,  Fig.  1).  Hence  the  condition  is  very  apt  to  be  con- 
founded with  true  neoplasms.  Small  gummatous  neo- 
plasms are  seen  even  more  rarely,  as  the  picture  soon 
becomes  obscured  by  confluence  or  disintegration  of  the 
infiltrate  (Plate  16,  Fig.  1).  The  delimitation  in  such 
cases  is  probably  explained  by  the  fact  that  the  process 
is  confined  to  individual  follicles ;  for,  as  a  rule,  the  in- 
dividual nodules  are  masked  not  only  clinically,  but  also 
histologically  (Plate  36,  Fig.  1),  by  the  presence  of  a 
diffuse  infiltrate  (Plate  23,  Fig.  2),  which  presents  nothing 
characteristic  until  ulceration  begins.     On  mucous  mem- 


120       SPECIAL  PATHOLOGY  AND  TREATMENT. 

branes,  as  on  the  skin,  we  may  observe  the  punched-out 
ulcer  with  a  characteristic  lardaceous  exudate  ou  its  floor 
(Plate  7,  Fig.  1;  Plate  10,  ¥\g.  3;  Plate  15,  Fig.  1  ; 
Plate  19,  Figs.  1,  2 ;  Plate  25,  l^ig.  1 ;  Plate  30,  Fig.  2), 
which,  after  it  clears  up,  leaves  sharply  defined  tissue 
defects  or  stellate  scars  (Plate  15,  Fig.  2 ;  Plate  19, 
Fig.  3).  The  seats  of  election  of  tertiary  ulcers  are,  in 
general,  those  portions  which  are  exposed  to  frequent  irri- 
tation and  other  injuries,  and  may,  therefore,  be  regarded 
as  loci  minoris  resistentiae.  They  include  the  soft  parts 
of  the  palate  and  the  anterior  portions  of  the  nose.  The 
hard  palate  becomes  involved  chiefly  from  the  propagation 
of  an  intranasal  infiltrate  in  the  floor  of  the  nose.  How- 
ever, all  the  various  parts  may  be  attacked,  as  we  see  by 
the  localization  of  the  disease  in  the  nasopharynx.  On 
the  lower  jaw  and  on  the  mucous  membrane  of  the  tongue 
tertiary  affections  are  practically  never  seen. 

The  ulcer  is  not  the  only  manifestation.  A  condition 
that  has  received  too  little  attention  and  is  probably,  on 
that  account,  so  refractory  to  treatment,  consists  in  diffuse 
and  extremely  chronic  infiltrates,  depending  chiefly  on 
alterations  in  the  blood-vessels.  These  do  not,  by  any 
means,  always  end  in  superficial  ulceration.  They  may 
imperceptibly  and  very  gradually  bring  about  atrophic  or 
hypertrophic  changes  in  the  connective  tissue  (Plate  25, 
Fig.  2).  In  the  nose  especially  atrophic  changes  occur 
under  the  form  of  "atrophic  rhinitis."  In  addition, 
tumors  resembling  polypi,  except  that  they  are  hard  and 
brittle,  are  formed  either  as  the  result  of  destructive 
processes  or  without  this  antecedent  cause.  These  tumors 
are  characterized  by  the  predominance  of  periarteritic 
changes.  The  symptoms  of  infiltrations  that  ultimately 
end  in  disintegration  may  at  first  be  very  deceptive,  as 
the  development  is  extremely  slow.  Intense  pain,  out  of 
all  proportion  to  the  visible  alterations,  a  subacute  course 
in  spite  of  violent  inflammatory  reddening,  and  a  tendency 
to  unilateral  distribution  or  isolation,  the  latter  when  the 
lesions  are  situated  near  the  median  line,  are  characteristic 


SYMPTOMATIC  PERSISTENT  INFLAMMATIONS.   121 

features  of  these  fetid  oropliaryngeal  foci.  In  the  nose 
the  characteristic  signs  are  great  obstruction,  with  radi- 
ating pains ;  the  presence  of  a  stale  odor  or  even  intense 
fetor ;  the  presence  of  hemorrliagic  crusts,  which,  unless 
they  are  situated  exactly  in  that  area  of  the  septum  which 
is  usually  injured  by  the  scratching  finger,  are  absolutely 
pathognomonic ;  and,  finally,  the  seat  of  the  infiltration, 
which  rarely  spares  the  floor  of  the  nose  or  the  middle 
portions  of  the  septum.  In  the  latter  location  the  linear 
extension  of  the  tissues  from  in  front  and  below  backward 
and  upward  is  especially  characteristic.  The  presence  of  a 
diffuse  macular  redness,  resembling  that  of  measles,  on 
any  portion  of  the  mucous  membranes ;  and  a  coppery 
discoloration  of  the  skin  covering  periosteal  and  peri- 
chondrial  foci,  combined  with  a  sense  of  resistance  and 
elasticity  to  the  finger,  should  always  excite  suspicion. 
Glandular  enlargement  is  rarely  absent. 

The  course  is  determined  by  the  breaking-down  of  the 
infiltrate,  which  almost  always  takes  place.  As  it  is 
usually  quite  extensive,  a  perforation  is  produced  in  those 
regions  that  are  exposed  on  either  side,  while  free  portions 
of  tissue  are  often  completely  destroyed.  All  degrees  of 
obstruction  are  observed,  from  fenestration  in  the  faucial 
arches  to  the  formation  of  a  wide  communication  between 
the  oropharynx  and  the  nose.  These  changes  produce 
very  troublesome  interference  with  swallowing  and  speak- 
ing. When  a  gumma  in  the  cartilage  or  on  the  bone  breaks 
down  primarily  or  as  the  result  of  nutritive  disturbances 
in  the  domain  of  the  supplying  blood-vessels,  extensive 
necrosis  with  the  formation  of  sequestra  results.  In  this 
way  the  entire  alveolar  process,  including  a  number  of 
teeth,  may  be  lost.  By  the  destruction  of  the  plates  of 
bone  that  form  the  boundaries  of  the  accessory  sinuses 
large  abnormal  communications  with  neighboring  cavities, 
or,  as  in  the  case  of  the  frontal  sinus,  with  the  skin,  are 
produced,  as  well  as  fistulse  which  lead  down  to  unex- 
pectedly large  deposits  of  dead  bone.  In  the  nose,  where 
the  septum  is  most  commonly  attacked,  the  quadrangular 


122       SPECIAL  PATHOLOGY  AND  TREATMENT. 

septal  cartilage  is  destroyed,  and  in  its  place  there  appears 
a  large  oval  perforation  (Plate  30,  Fig.  3),  the  edges  of 
which,  after  recovery  has  taken  place,  are  bounded  by 
cicatricial  contractions  of  the  mucous  membrane.  Such  a 
formation  of  radiating  scars  is  always  characteristic  of  a 
former  syphilitic  process  (Plate  19,  Fig.  3).  It  is  also 
responsible  for  the  depression  (retraction)  of  the  bridge 
of  the  nose  that  occurs  at  this  point,  and  that  is  described 
as  the  lorgnette  nose.  This  deformity  is  rarely  produced 
by  the  mere  loss  of  the  quadrangular  cartilage,  althougli 
the  latter  forms  the  chief  support  of  the  lower  skeleton 
of  the  nose.  Saddle-nose,  which  consists  in  depression  of 
the  upper  half  of  the  member,  is  also  to  be  attributed  to 
cicatricial  contraction  following  ulceration  of  the  per- 
pendicular plate  of  the  ethmoid  bone  and  of  the  nasal 
bones. 

Even  worse  than  these  ulcerations  are  the  adhesions 
that  so  frequently  form  in  the  throat,  either  by  the  ulccni- 
tion  of  adjacent  soft  parts  or  as  the  result  of  the  cicatricial 
contraction  already  referred  to.  Partial  or  total  occlusion 
of  the  mesopharynx  and  nasopharynx,  rhinolalia  clausa, 
and  closure  of  one  or  both  nares,  with  distressing  occlu- 
sion of  the  Eustachian  tubes,  are  among  the  conditions 
that  are  observed.  Sometimes  occlusion  of  the  orifice  of 
an  accessory  cavity  is  followed  by  dilatation  of  the  affected 
structure. 

Some  of  the  most  troublesome  symptoms  of  ulcerative 
processes  are  due  to  mixed  infection,  which  delays 
recovery  after  the  specific  infiltrate  has  become  absorbed, 
and  to  the  raetasyphilitic  alterations  that  are  chiefly  due 
to  nutritive  disturbances  of  the  blood-vessels.  These 
consist  in  atrophy  of  the  mucous  membrane  and  of  the 
muscles,  torpid  ulcers,  and  infiltrations  tiiat  are  not  aifected 
by  antisyphilitic  remedies,  and  granulation  tumors  with 
a  marked  tendency  to  recurrence.  The  same  refractory 
processes  are  sometimes  met  in  the  skin  of  the  nose  and 
of  the  upper  lip,  where  they  assume  the  form  of  su])er- 
ficial  nodules  which  extend  laterally  and  slowly  undergo 


SYMPTOMATIC  PERSISTENT  INFLAMMATIONS   123 

ulceration.  They  are  very  apt  to  be  confounded  with 
lupus  vulgaris. 

That  the  sequestra  of  cartilage  and  bone  may  keep  an 
ulcerative  process  alive  and  lead  to  the  constant  produc- 
tion of  fistulse,  the  cause  of  which  may  be  difficult  to 
determine,  is  readily  comprehensible. 

During  the  initial  stages,  while  infiltration  is  going  on, 
the  diagnosis  is  much  more  difficult  than  later  on,  when 
the  characteristic  ulcers  have  already  developed.  Unfor- 
tunately, the  condition  is  much  more  frequently  seen  dur- 
ing this  period  of  well-developed  necrosis,  when  medical 
aid  is  too  late ;  hence  the  great  importance  of  recognizing 
the  disease  in  its  early  stage.  In  addition  to  the  pecu- 
liarities detailed  above — namely,  unilateral  distribution  ; 
subacute,  very  severe  inflammation ;  intense  pain  ;  hem- 
orrhage ;  infiltration  of  the  glands ;  macular  redness ;  the 
predilection  evinced  for  certain  situations ;  and  the  odor — 
careful  inquiry  into  the  history  and  an  examination  of 
the  entire  body  must  be  depended  on  to  establish  the 
diagnosis.  In  women  the  occurrence  of  marked  falling 
of  the  hair  is  particularly  suspicious,  as  well  as  the  history 
of  premature  births,  still-births,  or  early  death  of  the  chil- 
dren. In  both  sexes  a  general  feeling  of  illness,  a  cachectic 
appearance,  and  violent  headache  occurring  chiefly  at 
night,  are  significant  symptoms.  With  the  greatest  care, 
however,  the  diagnosis  may  remain  in  doubt  and  have  to 
be  determined  by  the  therapeutic  test. 

Treatment. — The  sovereign  remedy  is  potassium  iodid. 
It  should  be  exhibited  at  once  in  large  doses : 

i;^  Sol.  kal.  iod.,  (10.0-15.0)150.0 
Sod.  carl).,  0.5 

Syr.  aurantii  cort.,  25.0 

^      Sig. — One  tablespoonful  three  times  a  day. 

The  addition  of  the  alkali  guards  against  iodism  or 
holds  it  in  check  after  it  has  developed. 

Superficial  ulcers  may  be  cauterized  once  with  a  crystal 


124       SPECIAL  PATHOLOGY  AND  TREATMENT. 

of  chromic  acid  to  alleviate  the  pain  and  to  combat  mixed 
infection.  The  crystal  is  carefully  fused  on  the  end  of  a 
heated  probe.  In  pharyngeal  disease  gargles  should  be 
used  with  great  caution.  The  patient  may  gently  rinse 
his  mouth  with  a  lukewarm  alkaline  solution.  In  the 
nose  the  crusts  must  be  softened  with  liquid  vaselin,  after 
which  a  cleansing  solution  should  be  drawn  up  into  the 
nostrils.  Necrosis  is  searched  for  with  a  probe.  During 
the  early  stages  decay  of  the  bone  may  be  checked  by 
opening  up  the  diseased  areas  as  freely  as  possible,  and 
packing  with  iodoform  gauze  so  as  to  guard  against  mixed 
infection.  Sequestra  must  be  removed  as  soon  as  pos- 
sible. The  torpid  ulcers  of  the  later  stage  may  be  treated 
advantageously  with  the  sharp  spoon.  During  this  stage, 
when  the  specific  poison  has  ceased  to  act,  little  is  to  be 
hoped  from  internal  medication  except  in  the  form  of 
mercury  to  prevent  occurrence  of  fresh  lesions,  while,  on 
the  other  hand,  energetic  surgical  cleansing  is  of  the  great- 
est value.  Broad  surfaces  covered  with  torpid  granulations 
and  dense  bands  of  connective  tissue  interspersed  with 
islands  of  badly  nourished  tissue  keep  up  the  inflamma- 
tory condition  for  years  ;  they  may  be  freshened  up  advan- 
tageously with  the  actual  cautery.  Syphilitic  lupus  at  the 
entrance  of  the  nose  and  in  the  skin  ought  to  be  treated 
in  exactly  the  same  way  as  the  tuberculous  form  of  the 
disease. 

The  final  results  of  syphilitic  disease  often  require 
surgical  aid.  Perforations  and  tissue  losses  in  the  soft  or 
hard  palate  should  be  covered  in,  if  possible,  by  means 
of  staphylorrhaphy,  or  a  staphyloplastic  operation,  or,  if 
these  measures  fail,  plugged  with  an  obturator.  The 
cicatricial  contraction  of  the  alae  nasi  and  the  deformities 
of  the  bridge  of  the  nose  can  also  be  corrected,  or  at  least 
mitigated  by  surgical  means.  Adhesions  between  the 
soft  palate  and  the  posterior  wall  of  the  pharynx  are  very 
difficult  to  treat.  After  the  adhesions  have  been  divided 
and  the  contiguous  surfaces  freshened  up,  a  new  epithelial 
covering  to  guard  against  the  formation  of  fresh  adhesions 


SYMPTOMATIC  PERSISTENT  INFLAMMATIONS.   125 

may  be  secured  by  making  a  perforation  on  each  side  and 
keeping  these  packed  with  gauze  until  epithelium  is 
formed,  when  the  tissues  between  the  two  are  divided  so 
as  to  form  a  broad  separation.  Epithelialization  of  this 
surface  is  then  secured  by  means  of  constant  packing, 
since  the  outer  angles,  where  new  adhesions  are  most 
likely  to  form,  are  already  covered  with  epithelium. 
Permanent  or  periodic  dilatation  of  the  artificial  openings 
by  means  of  tampons  or  a  dilator  may  be  necessary  both 
here  and  in  other  regions.  Before  any  plastic  operation 
is  attempted,  the  original  disease  must,  of  course,  be  cured 
beyond  the  possibility  of  a  recurrence.  [One  of  the  most 
efficacious  operations  for  the  relief  of  this  condition,  espe- 
cially in  the  permanency  of  its  results,  is  that  devised  by 
the  late  J.  E.  H.  Nichols,  of  New  York.  The  procedure 
consists  in  inserting  a  thread  loop  through  the  base  of  the 
adhesion,  leaving  it  there  until  cicatrization  has  taken 
place  around  it,  and  then  cutting  through  the  adhesion 
and  leaving  the  edges  to  heal,  reunion  always  being  pre- 
vented by  the  presence  of  the  narrow  strip  of  cicatricial 
tissue  at  the  base  of  the  cut.  In  other  words,  the  adhe- 
sion is  treated  as  are  webbed-fingers.  The  operation  is 
fully  described  in  the  Transactions  of  the  Ameincan 
Laryngological  Association  for  1896,  p.  166. — Ed.] 

GLANDERS. 

It  seems  advisable  at  this  place  to  introduce  the  subject 
of  glanders,  as  this  disease,  fortunately,  manifests  itself 
usually  in  a  chronic  form  in  man,  acute  malignant  cases 
being  quite  rare. 

Infection  is  usually  derived  directly  from  the  horse, 
rarely  from  another  diseased  human  being.  AVhile  in  the 
horse  the  mucous  membranes  of  the  upper  air-passages 
are  always  involved,  they  may  escape  in  the  human  sub- 
ject, in  whom  cutaneous  ulcers,  gastro-intestinal  catarrh, 
i)ronchial  disease,  and  symptoms  of  pyemia  dominate  the 
clinical  picture.    The  disease  does  not  acquire  its  peculiar 


126        SPECIAL  PATHOLOGY  AND   TREATMENT. 

character  unless  the  characteristic  eruption  appears  in  the 
nose,  mouth,  and  pharynx.  The  eruption  consists  of 
pustules  which  become  converted  into  punched-out  ulcers, 
and  are  followed  by  phlegmons  and,  later,  by  extensive 
destruction  of  the  bony  framework.  Before  long  the 
outer  skin  of  the  nose  becomes  involved  and  presents  an 
erysipelatous  inflammation  terminating  in  ulceration. 

In  acute  cases  the  result  is  very  often  fatal.  In  chronic 
cases  the  course  is  very  protracted,  as  the  ulcers  are  re- 
fractory to  treatment,  and  the  cicatricial  contraction  that 
follows  leaves  great  deformities.  Perfect  recovery  occurs 
only  in  about  10  to  12  per  cent,  of  the  cases. 

The  diagnosis  is  based  on  the  demonstration  of  the 
typical  bacilli,  which  must  be  identified  by  means  of 
animal  inoculation,  and,  above  all,  on  a  careful  history 
of  the  case.  Care  is  requisite  to  guard  against  confusion 
with  syphilis,  which  this  disease  often  greatly  resembles. 

The  treatment  consists  in  early  and  radical  extirpation 
of  the  diseased  foci  Avith  the  actual  cautery.  Potassium 
iodid  in  large  doses  is  said  to  exert  a  distinctly  favorable 
influence. 

TUBERCULOSIS. 

Tuberculosis  of  the  mucous  membranes  of  the  mouth, 
nose,  and  throat  occurs  either  in  the  course  of  an  extensive 
pulmonary  phthisis,  usually  as  a  terminal  manifestation, 
or  primarily  as  the  result  of  infection  introduced  from 
without.  In  the  first  form  symptomatic  treatment  only 
is  applicable  the  second,  on  the  other  hand,  calls  for 
active  therapeutic  measures,  es})ecially  as  it  has  been 
found  that  while  the  symptomatic  lesions  evince  a  marked 
tenden(!y  to  ulceration,  primary  tubercular  disease  pre- 
sents the  true  type  of  an  inoculation  tub(>rculosis,  and  is 
characterized  by  a  torpid  course,  with  distinct  tendency 
to  cicatrization.  In  a  general  way  it  may  be  said  that 
"  endogenous"  forms  are  more  frequent  in  the  oropharynx, 
while  "  ectogenous "  forms  are  most  frequently  observed 
in  the  nose.     The  oropharynx  usually  becomes  infected 


SYMPTOMATIC  PERSISTENT  INFLAMMATIONS  127 

through  the  sputum,  the  infectious  material  effecting  en- 
trance through  fissures  or  defects  in  the  tissues.  At  the 
entrance  to  tlie  nose,  where  the  locahzation  is  chiefly  in 
the  anterior  portion  of  the  floor  and  on  the  cartilagi- 
nous septum,  the  infectious  material  is  introduced  by  the 
scratching  finger,  so  that  the  infiltration  at  first  is  strictly 
confined  to  the  area  accessible  to  the  finger.  The  case 
illustrated  on  Plate  2,  Fig.  2,  is  a  good  example  of  sputum 
infection.  Rhagades  are  particularly  common  at  the 
angles  of  the  mouth ;  carious  teeth  and  fissures  of  the 
gums  have  also  with  good  reason  been  regarded  as  fre- 
quent ports  of  entry.  The  disease  in  that  case  usually 
spreads  to  the  respective  regions,  and  in  both  forms  its 
progress  is  very  slow. 

Other  ports  of  entry  that  should  be  especially  borne  in 
mind  are  the  crypts  in  the  pharyngeal  lymphatic  ring, 
where  the  carriers  of  infection  are  deposited  either  by 
inhalation  or  during  the  ingestion  of  food.  It  is  true  that 
in  this  region  the  bacilli  are  more  apt  to  pass  through  the 
lymphatic  region  and  exert  their  influence  on  the  nearest 
glands,  than  they  are  to  produce  alterations  in  the  lym- 
phatic ring  itself.  The  changes  are  usually  confined  to 
the  deeper  portions  of  the  follicles,  and  can  be  discovered 
only  by  microscopic  examination.  Their  clinical  signifi- 
cance is,  therefore,  to  say  the  least,  dubious,  and  has 
never  been  fully  explained. 

Tuberculosis  manifests  itself  in  the  following  forms : 
Superficial  aphthous  ulcer  (Plate  2,  Fig.  2) ;  an 
infiltration  presenting  the  character  of  granulation 
tissue  (Plate  17,  Fig.  3;  Plate  30,  Fig.  1);  the  poly- 
poid tumor,  which  may  attain  the  size  of  a  walnut 
(Plate  36,  Fig.  2) ;  the  deep  ulcer  (Plate  4,  Fig.  1) ;  and 
the  small  nodular  lupOUS  infiltrate  (Plate  16,  Fig.  2). 

All  these  affections  have,  in  common,  a  bossellated 
appearance  of  the  lesion  itself  or  of  the  surrounding 
tissues,  due  to  its  origin  in  the  tubercle.  The  infiltrations 
are  moderately  firm  ;  tlie  tumors  are  softer,  more  brittle, 
bleed  readily  when  irritated  j  the  floor  of  the  ulcers  is 


128        SPECIAL  PATHOLOGY  AND  TREATMENT. 

rather  shallow,  the  edges  are  irregular  and  granular, 
never  punched  out,  like  those  of  syphilis.  From  the  latter 
affection  tuberculosis  is  also  distinguished  by  tiie  pallor 
of  the  surrounding  tissue,  the  absence  of  scars,  extremely 
slow  development,  which  may  extend  over  months  or 
even  years,  and,  subjectively,  by  the  insignificance  or 
entire  absence  of  pain,  coupled  with  a  marked  sensation 
of  dryness  and  tension.  All  these  factors  must  be  duly 
taken  into  consideration  in  making  up  the  diagnosis, 
which  in  a  doubtful  case  may  be  confirmed,  in  a  negative 
sense,  by  the  administration  of  potassium  iodid,  and, 
in  a  positive  sense,  by  the  injection  of  tuberculin.  The 
tubercle  bacilli  are  very  difficult  to  find,  as  they  are  not 
present  on  the  surface,  and  must,  therefore,  be  looked  for 
in  the  deeper  tissues. 

The  course  is  slow,  but  almost  never  benign  ;  the  infil- 
trate either  undergoes  superficial  ulceration  or  it  gradu- 
ally extends  deeper  and  consumes  the  adjoining  tissues 
like  a  malignant  tumor,  so  that  in  exploring  with  a  probe 
the  instrument  suddenly  slips  into  large  homogeneous 
masses  of  disintegrated  tissue.  The  bone  itself  is  gradu- 
ally eaten  away  and  replaced  by  granulomatous  tissue, 
the  process  in  this  respect  presenting  a  marked  difference 
to  syphilitic  decay,  since  sequestrum-formation  is  ex- 
tremely rare.  Extending  in  this  way,  the  infection  ulti- 
mately invades  contiguous  spaces  :  from  the  nose  it  passes 
into  the  mouth  (Plate  17,  Fig.  3),  or  into  any  one  of  the 
accessory  sinuses,  or  even  into  the  skull ;  or  from  the 
month  into  the  antrum.  It  is  probable  that  the  skull  is 
also  reached  by  way  of  the  lymph-channels,  and  it  is  not 
unlikely  that  tubercular  meningitis  occurs  chiefly  at  the 
base  of  the  skull,  because  of  the  extraordinary  frequency 
of  tubercle  bacilli  in  the  adenoid  tissue  of  the  nasopharynx 
and  of  the  readiness  with  which  they  enter  the  subdural 
lymph-spaces. 

The  prognosis  is  most  favorable  in  the  lupoid  forms 
and  those  characterized  by  the  presence  of  tumors,  as  the 
diseased  tissue  can  then  be  readily  extirpated. 


SYMPTOMATIC  PERSISTENT  INFLAMMATIONS.  129 

The  indications  for  treatment  are  found,  first  of  all,  in 
the  general  condition.  The  presence  of  advanced  phthisis 
renders  success  extremely  improbable,  and  even  if  the 
local  treatment  proves  successful,  the  relief  will  in  all 
probability  be  too  late.  However,  if  the  respiration  is 
aifected  or  any  other  distressing  symptom  justifies  the 
procedure,  a  surgical  intervention  may  be  indicated. 
Obstructing  tumors  and  swellings  should  be  removed  or 
reduced  to  a  minimum.  Ulcers  may  be  touched  with  a 
50  per  cent,  solution  of  lactic  acid  or  cleansed  with  the 
curet  or  the  actual  cautery,  but  these  procedures  merely 
satisfy  symptomatic  indications. 

The  case  is  different  in  local  tuberculosis  occurring 
in  otherwise  healthy  or  practically  healthy  individuals. 
Complete  extirpation  of  the  focus  or  foci  is  then  possible, 
and  is,  therefore,  indicated.  As  it  is  most  important  to 
prevent  the  spread  of  the  disease,  operative  measures 
must  include  the  healthy  tissue  surrounding  the  lesions, 
it  being  borne  in  mind  that  the  infiltration  always  extends 
beyond  the  area  that  is  visibly  diseased.  Caustics  should, 
therefore,  be  freely  used,  as  they  destroy  any  germs  that 
may  remain  on  the  wound  surfaces.  In  tubercular  dis- 
ease at  the  entrance  to  the  nose,  no  matter  how  small  the 
diseased  focus,  I  am  distinctly  opposed  to  any  operation 
per  vias  naturales.  The  affected  side  of  the  nose  should 
be  at  once  laid  open  as  described  on  p.  51,  and  the  lesion 
excised  with  a  zone  of  healthy  tissue  by  means  of  the  cut- 
ting cautery.  During  the  after-treatment  iodoform  should 
be  used  whenever  possible.  The  patient  must,  of  course, 
be  kept  under  observation  for  some  time,  so  that  any 
recurrences  may  at  once  be  recognized. 

LEPROSY. 

Leprosy  has  recently  gained  a  peculiar  interest  for  the 
rhinologist  from  the  fact  that  in  a  great  number  of  cases 
it  appears  to  be  extremely  probable,  if  not  actually  proved, 
that  the  primary  lesion  is  seated  in  the  nose  on  the  ante- 


130       SPECIAL  PATHOLOGY  AND   TREATMENT. 

rior  portion  of  the  septum  ;  in  other  words,  the  infection 
eifects  an  entrance  at  the  same  point  as  that  of  tubercu- 
losis. This  fact  also  explains  the  mystery  that  leprosy 
is  transmitted  from  one  individual  to  another,  but  is  not 
contagious  in  the  ordinary  sense  of  the  word,  as  this  mode 
of  infection  is  to  be  explained  only  on  the  supposition 
that  the  infectious  material  is  conveyed  by  the  scratching 
finger. 

The  first  signs  of  the  disease  then  usually  appear  in 
the  interior  of  the  nose  and  rarely  on  the  exterior,  while 
pharyngeal  lesions  make  their  appearance  later  along  with 
the  cutaneous  eruptions. 

At  first  there  is  a  diffuse  infiltration  (Plate  16,  Fig.  3, 
lip),  within  which  sharply  defined,  large  and  small  nodules 
of  moderately  firm,  and  sometimes  elastic  consistence  and 
of  pale  or  waxy  color  develop  (Plate  16,  Fig.  3,  pharynx). 
The  individual  stages,  which  are  readily  observed  in  the 
pharynx,  cannot  be  distinguished  in  the  nose,  because  the 
swelling  of  the  interior  tissues  and  the  obstruction  from 
the  external  nodules  soon  combine  to  make  inspection 
impossible.  The  nodules  speedily  ulcerate  and  break 
down,  leaving  large  defects  surrounded  by  scars.  Mean- 
while other  portions  are  attacked  by  other  stages  of  the 
process,  producing  a  polymorphous  clinical  picture.  Even 
the  underlying  bone  is  destroyed  ;  extensive  portions  of 
the  palate,  the  skeleton  of  the  nose  and  its  soft  parts,  or 
even  the  entire  member  is  sacrificed,  but  without  the 
separation  of  true  sequestra,  as  the  bone  undergoes  carious 
disintegration.  Owing  to  the  great  tendency  to  cicatri- 
zation, stenoses  and  adhesions  are,  of  course,  quite  com- 
monly seen. 

The  symptoms  consist  at  first  of  violent  and  protracted 
coryza,  with  watery,  sanguineous  secretion ;  the  presence 
of  great  swelling  and  anesthesia,  which  may  even  aifect 
apparently  normal  parts ;  and  angina,  which  may  be  so 
severe  that  the  patient  refuses  to  take  food ;  and,  finally, 
salivation. 

The  diagnosis  is  made  by  the  characteristic  anesthesia 


SYMPTOMATIC  PERSISTENT  INFLAMMATIONS.   131 

and  tlie  peculiar  appearance  and  seat  of  the  nodes,  which 
in  the  oropharynx  preferably  attack  the  symphysis  of  the 
palate  and  the  posterior  arches.  In  addition,  the  com- 
plicating cutaneous  and  nervous  phenomena  and,  in  doubt- 
ful cases,  the  demonstration  of  the  lepra  bacillus  in  the 
secretions  are  valuable  diagnostic  aids.  Although  there 
is  a  superficial  resemblance  to  tuberculosis  and  syphilis, 
the  distinction  is  readily  made  by  observing  the  course 
of  the  disease.  The  diagnosis  may  possibly  become  ob- 
scured if  a  complication  with  one  or  the  other  of  these 
infections  exists. 

The  treatment  consists  solely  in  relief  of  the  symptoms. 

SCLEROMA. 

Scleroma  constitutes  a  specific  disease  of  the  upper  air- 
passages — so  much  so  that  until  quite  recently  it  was 
known  under  the  name  of  rhinoscleroma.  It  is  charac- 
terized by  an  exceedingly  slow  course,  measured  not  by 
years,  but  by  decades ;  and  usually  begins  in  the  posterior 
portion  of  the  nose,  so  that  the  first,  and  for  a  long  time 
the  only,  symptom  consists  in  chronic  nasal  catarrh,  the 
production  of  tenacious  crusts,  and  slight  obstruction. 
The  disease  does  not  become  characteristic  until  it  ex- 
tends downward  or  forw^ard  and  produces  material  altera- 
tions in  the  pharynx  or  at  the  entrance  to  the  nose.  The 
pathologic  basis  consists  in  pale,  cartilaginous,  nodular  or 
rarely  diffuse  infiltration  of  the  mucosa  itself,  much  more 
rarelv  affecting  also  the  deeper  layers,  and  followed  sec- 
ondarily by  great  shrinking  of  the  tissues,  w^hich  may 
also  involve  contiguous  regions.  The  surface  may  be- 
come slightly  eroded  in  places,  but  true  ulcers  are  never 
formed.  On  the  other  hand,  the  uvula  is  quite  apt  to 
contract  and  disappear  as  if  it  had  been  removed  with  a 
razor ;  the  cartilages  of  the  nose  in  some  instances  are 
completely  destroyed  by  the  pressure  of  the  growing 
tumors.  If  contraction  has  begun,  it  reveals  itself  by  the 
presence  of  white,  radiating  scars.     During  the  stage  pre- 


132       SPECIAL  PATHOLOGY  AND  TREATMENT. 

ceding  the  cicatricial  process  small,  flat,  hard  nodes  or 
larger  masses  of  granuloma,  which,  for  example,  may 
occlude  the  nasopharynx,  and  finally  wide-!^pread  stenoses 
due  to  the  retraction  of  the  tissues,  make  up  the  picture 
of  the  disease.  The  posterior  arches  and  the  soft  palate 
are  retracted  and  completely  shut  oiF  the  nasopharynx. 
The  salpingopharyngeal  folds  are  so  stretched  as  to  evert 
the  margins  of  the  tubal  orifices,  and  the  entrance  to  the 
nose  is  greatly  narrowed  by  retraction  of  the  septum  and 
of  the  alae. 

During  the  initial  stage,  as  long  as  the  superficial  layer 
only  is  attacked  and  undergoes  contraction,  the  mucous 
membrane  of  the  nose  itself  may  merely  present  the 
appearance  of  atrophy,  an  appearance  that  is  accentuated 
by  the  presence  of  inspissated  masses  of  pus. 

The  disease  is  common  in  eastern  Europe,  but  occurs 
only  sporadically  in  other  portions  of  the  globe. 

The  diagnosis  is  based  on  the  extremely  slow  course, 
the  cartilaginous  hardness  of  the  infiltrations  and  of  the 
scars,  and  on  the  finding  of  Mikulicz's  cells  in  the  tissues. 
These  cells  and  the  hyaline  corpuscles  contain  the  specific 
bacillus  of  scleroma,  which  may  also  be  found  in  the 
secretion. 

No  trustworthy  causal  treatment  has  as  yet  been  dis- 
covered ;  excision  of  individual  portions  of  tissues  that 
are  particularly  troublesome  and  the  production  of  arti- 
ficial openings  when  required  by  the  presence  of  adhesions 
are  the  only  therapeutic  measures  at  our  disposal. 

ACTINOMYCOSIS. 

Actinomycosis  represents  the  rarest  form  of  chronic 
infectious  inflammation.  The  ray-fungus  gains  entrance 
to  the  organism  through  the  instrumentality  of  objects 
that  have  come  in  contact  with  diseased  cattle,  or  enters 
directly  with  vegetable  particles,  such  as  kernels  of  corn 
and  the  like,  in  which  the  fungus  grows.  This  explains  the 
frequent  localization  of  the  disease  in  the  mouth.     Carious 


SYMPTOMATIC  PERSISTENT  INFLAMMATIONS.  133 

teeth  and  wounds  of  the  gums  are  the  favorite  ports  of 
entry,  but  the  tongue  may  also  be  attacked  independently. 
In  the  former  case  chronic  periosteal  abscess  usually 
forms  on  the  lower  jaw  ;  more  rarely  a  central  osteitis  is 
produced.  When  the  infection  is  conveyed  directly 
tlirough  the  mouth,  a  slowly  growing,  hard,  sharply  out- 
lined tumor  appears  at  the  tip  of  the  tongue,  more  rarely 
at  the  margin  or  in  the  middle,  and  sometimes  undergoes 
softening.  The  lingual  tumor  may  be  mistaken  for  a 
gumma  or  carcinoma,  and  it  is  to  be  remembered  that 
potassium  iodid  appears  to  have  some  influence  on  the 
disease  under  discussion,  so  that  it  cannot  be  employed  as 
a  therapeutic  test  to  exclude  syphilis. 

A  positive  diagnosis  can  be  made  only  by  finding  the 
characteristic  ray-fimgi  in  the  secretion  or  in  the  tissues. 

The  treatment  is  chiefly  surgical,  and  consists  in  free 
excision  of  the  foci.  It  may  be  efficiently  supported  by 
the  administration  of  large  doses  of  potassium  iodid. 


APPENDIX. 


INFLAMMATORY  DISEASES  AND  HYPER- 
PLASIAS OF  THE  LYMPHATIC  RING. 

The  various  portions  of  the  lympliatic  ring  being 
similar  in  structure  and  embryologic  origin,  and  the 
pathologic  conditions,  therefore,  approximately  the  same, 
the  diseases  of  the  individual  parts  may  be  discussed 
together. 

Acute  inflammations  presenting  the  familiar  picture 
of  lacunar  tonsillitis  occur  chiefly  in  the  palatal  tonsils. 
The  inflammatory  process  becomes  localized  in  the  iieeper 
lacunae  or  crypts,  which  present  a  good  opportunity  for 
the  inflammatory  secretions  to  stagnate.  The  constitu- 
tional sjrmptoms  are  often  marked ;  the  temperature  rises 
to  29.5°  C.  (103.2°  F.),  and  in  children  even  higher. 
Headache  and  pain  in  the  limbs  are  present ;  the  patient 
is  much  depressed ;  and  a  feeling  of  dryness  and  choking 
in  the  throat  points  to  the  chief  focus  of  the  infection. 
At  first  no  more  than  a  reddening  of  the  central  portions 
of  the  pharynx  is  observ'able.  On  the  following  day,  how- 
ever, the  tonsils  appear  greatly  swollen  and  covered  with 
a  yellowish-white  exudate,  corresponding  in  distribution 
to  the  crypts  and  extending  into  these  structures  (Plate  8, 
Fig.  1).  In  the  course  of  a  few  days  the  exudate,  which 
in  the  main  consists  of  recent  and  necrotic  pus-corpuscles, 
some  epithelium,  and  a  good  many  microbes,  breaks  down 
and  the  entire  symptom-complex  begins  to  subside. 

The  localization  and  the  great  tendency  to  recurrence 
observed  in  this  peculiar  disease,  which,  however,  is  not 
at  all  rare,  throw  some  light  on  the  pathogenesis.  Thus 
134 


ACUTE  INFLAMMATIONS.  135 

these  peculiarities  explain  the  fact  that  an  ordinary  cold 
very  frequently  appears  to  be  the  only  exciting  cause. 
Lacunar  angina  is,  so  to  speak,  a  preformed  disease — that 
is,  it  attacks  individuals  in  whom  the  lacunae  are  either 
abnormally  deep  or  somewhat  branching,  permitting  the 
pathogenic  fission-fungi  which  are  present  in  the  mouth 
of  every  healthy  person  to  develop  into  large  colonies. 
The  crypts,  which  are  constantly  irritated  by  the  action 
of  metabolic  products,  appear  to  present  a  locus  vunoris 
resistentke  to  the  secondary  determination  of  blood  to  the 
inner  organs  whenever  the  individual  catches  cold.  In 
addition  to  the  ubiquitous  fungi,  a  sudden  immigration 
of  streptococci  and  staphylococci,  which  are  either  facul- 
tatively pathogenic  or  at  once  exert  their  deleterious 
influence,  appears  probable  from  the  fact  that  cases  are 
not  infrequently  observed  in  Avhich  infection  is  directly 
carried  to  a  healthy  person  by  one  affected  with  angina. 
The  attacks  occurring  after  operations  on  the  nose  and 
on  the  teeth  are  in  part  due  to  direct  infection  ;  but  in  the 
majority  of  instances  they  probably  resemble  the  inflam- 
mations due  to  cold  in  that  they  depend  on  certain  insuf- 
ficiently explained  processes  that  follow  in  the  wake  of 
a  determination  of  blood  to  the  part. 

The  characteristic  picture  of  lacunar  inflammation  in 
the  subsequent  course  of  the  disease  becomes  obscured  by 
the  prominence  of  the  products  of  desquamation.  The 
latter  may  extend  over  the  surface  of  the  tonsils;  the 
epithelium  covering  the  intervals  between  the  lacunae 
undergoes  coagulation  necrosis,  and  thus,  by  the  produc- 
tion of  fibrin,  benign  fibrinous  angina  is  produced  (Plate 
8,  Fig.  2).  This  somewhat  rare  event  may  give  rise  to 
confusion  with  diphtheria.  The  error  may  be  guarded 
against,  however,  by  bacteriologic  examination  and  by 
remembering  that  the  membranes,  since  they  consist  solely 
of  epithelium,  readily  come  away  without  producing  hem- 
orrhage— that  is  to  say,  without  any  destruction  of  tissue. 

As  a  result  of  the  inflammation  the  lacunae  become 
dilated,  since  they  are  bounded  only  by  the  lymph-fol- 


136  APPENDIX. 

licles,  and  the  material  from  the  latter  structures  itself 
contributes  to  the  inflammatory  leukocytosis.  The  fol- 
licles break  down  and  give  up  the  material  they  contained, 
as  shown  on  Plate  31,  Fig.  3  (in  a  pharyngeal  tonsil). 
Small  cavities  are  formed,  and  later,  owing  to  destruc- 
tion of  the  dividing  septa,  coalesce  with  the  adjt>ining 
spaces. 

It  is  this  dilatation  of  the  lacunae,  coupled  with  the 
accumulation  of  secretion  in  the  form  of  inspissated  or 
even  calcified  concretions  within  the  lacunte,  that  is  re- 
sponsible for  the  tendency  to  recurrence,  and  persists  in 
many  individuals  until  the  cavities  have  been  entirely 
obliterated,  either  artificially  or  through  the  action  of  the 
morbid  process. 

The  concretions  referred  to  frequently  give  rise  to  a 
number  of  symptoms  without  producing  an  actual  recur- 
rence of  the  inflammation,  and  as  they  are  hidden  away 
in  the  depths  of  the  lacunae,  they  not  infrequently  escape 
observation  for  some  time.  The  feeling  of  a  foreign 
body  ;  the  constant  desire  to  swallow  and  choke ;  expec- 
toration of  mucus  in  the  morning,  occasionally  mixed 
with  small  quantities  of  blood  ;  and,  finally,  the  subjective 
sense  of  a  bad  odor — these  are  the  ambiguous  symptoms 
complained  of.  If  in  such  a  case  the  more  common 
sources  of  these  symptoms — catarrh  of  the  nose  and  of 
the  accessory  sinuses,  hypersecretion  of  the  naso])harynx, 
and  similar  conditions — are  not  found,  the  tonsils  should 
be  examined  carefully  even  if  their  external  appearance 
presents  nothing  suspicious.  If  the  tonsils  are  manifestly 
altered,  fissured,  or  partially  destroyed  ;  if  small  yellowish 
points  are  seen  on  the  individual  lacunae,  the  condition, 
of  course,  will  not  be  overlooked.  In  all  such  cases  the 
pockets  from  which  concretions  protrude  must  be  explored 
with  the  probe,  or,  if  no  such  pockets  are  seen,  the  probe 
should  be  passed  from  below  upward  over  the  surface  of 
the  tonsil  for  the  purpose  of  bringing  any  hidden  plugs 
that  there  may  be  into  view.  To  return  to  the  angina : 
the  above-described  symptoms  sometimes  manifest  them- 


ACUTE  INFLAMMATIONS.  137 

selves  without  the  appearance  of  the  ominous  secretions 
at  the  openings  of  the  lacunae ;  in  some  cases  there  may 
be  more  marked  dysphagia ;  in  others  a  variable  degree  of 
nasal  obstruction,  for  it  is  to  be  remembered  that  lacunar 
inflammation  of  the  lingual  and  of  the  pharyngeal  tonsils 
while  much  more  rare  than  in  the  palatal  tonsil,  is  not  im- 
possible and  may  be  inferred  if  the  above-described  phe- 
nomena are  present.  A  positive  diagnosis  can,  of  course, 
be  made  only  when  the  characteristic  formation  of  puru- 
lent plugs  is  actually  seen  in  the  lingual  and  pharyngeal 
tonsils  (Plate  21,  Fig.  1).  Their  occurrence  in  the  lin- 
gual tonsil  in  association  with  ordinary  inflammation  of 
the  palatal  tonsil  is  not  so  very  rare.  That  the  lingual 
and  pharyngeal  tonsils  are  less  subject  to  disease  than  the 
palatal  tonsils  is  due  partly  to  their  protected  position  and 
the  fact  that  the  surface  is  more  frequently  cleansed 
meciianically,  and  partly  to  the  fact  that  the  openings 
of  the  crypts  of  the  pharyngeal  tonsil  are  hidden  and 
directed  downward,  thus  facilitating  the  escape  of  the 
secretions. 

Nevertheless,  the  secondary  changes  described  may 
also  appear  in  these  portions  of  the  pharyngeal  ring. 

A  description  of  lacunar  inflammation  of  the  pharyngeal 
ring  would  be  anything  but  complete,  in  fact,  would  be 
lacking  in  an  important  essential,  if  it  failed  to  include 
the  complications,  which  are  often  much  more  important 
than  the  local  condition.  In  the  majority  of  cases  the 
invading  army  of  cocci  encounter  the  resistance  of  the 
inflamed  follicles ;  these  immediately  pour  out  numbers 
of  leukocytes  into  the  intervening  spaces,  and  the  advance 
guard  is  checked  by  the  lymph-glands  of  the  aifected 
region,  so  that,  without  exception,  glandular  enlargement 
accompanies  every  attack  of  angina.  But  as  soon  as  the 
normal  outpouring  of  leukocytes  begins  to  be  insufficient, 
there  is  not  in  the  whole  body  a  better  port  of  entry  for  the 
invasion  of  fungi  that  have  not  been  damaged  by  secre- 
tions than  is  found  in  the  lacunae  of  the  tonsils.  Accord- 
ingly it  is  common  to  see,  after  tonsillitis,  irritations  or 


138  APPENDIX. 

even  grave  inflammations  of  the  serous  membranes.  In- 
deed, clinical  experience  makes  it  probable  that  the 
source  of  various  inflammations  of  serous  membranes  in 
which  no  other  definite  cause  can  be  discovered  is  to  be 
sought  in  the  pharyngeal  ring,  whether  the  latter  has 
been  acutely  diseased  or  only  predisposed  to  the  reception 
of  pathogenic  germs  on  account  of  former  attacks  or  of 
some  structural  abnormality.  The  whole  army  of  these 
acute  febrile  and  sometimes  very  harmful  inflammations 
of  serous  membranes  has  not  inaptly  been  attributed  to 
cryptogenetic  septicopyemia,  and  this  is  true,  but  in  a 
special  sense  of  the  term,  since  they  arise  from  the  crypts 
of  the  tonsils.  These  aifections,  including  pleuritis, 
endo-  and  pericarditis,  and  polyarthritis  and  the  cutaneous 
manifestjitions  by  which  tliey  are  accompanied  (purpura, 
erythema  nodosum,  and  the  like),  have  long  been  recog- 
nized as  ])ossessing  a  certain  causal  connection,  and  this 
is  now  explained  by  the  discovery  of  their  common  origin. 
Slight  irritations,  especially  of  the  joints,  are  unques- 
tionably much  more  common  than  is  generally  supposed, 
because  no  mention  is  made  of  them  and  they  sink  into 
insignificance  beside  the  febrile  pain.  On  the  other  hand, 
the  more  severe  aflections  of  the  serous  membranes  so 
dominate  the  picture  that  the  original  angina  is  quite 
overlooked,  or  at  least  forgotten,  and,  as  the  pathogenesis 
is  not  determined,  the  proper  measures  to  prevent  recur- 
rence of  the  attacks  are  neglected. 

Am(mg  the  rare  diseases  of  serous  membranes  is  inflam- 
mation of  the  tunica  vaginalis  of  the  testicle.  A  number 
of  cases  of  this  form  of  orchitis  and  one  case  of  perito- 
nitis have,  however,  been  observed.  That  disseminated 
metastases  of  true  pyemic  character — septicophlebitis — 
occasionally  occur  is  readily  understood  from  what  has 
been  said. 

Even  pneumonia  has  been  observed  to  follow  lacunar 
angina  in  a  number  of  instances,  although  the  bacteriologic 
connection  was  not  very  clear,  while,  on  the  other  hand, 
in  the    inflammations   of  serous   membranes   the   same 


CATARRH  AND  SUPPURATION  OF  MIDDLE  EAR.    139 

streptococci  and  staphylococci  were  found  as  in  the 
original  angina. 

The  occurrence  of  a  febrile  albuminuria  or  true  ne- 
phritis after  tonsillitis  presents  nothing  characteristic, 
as  it  is  a  phenomenon  common  to  all  acute  infectious 
diseases. 

In  connection  with  the  pathogenesis  of  general  septico- 
pyemia the  fact  is  worth  mentioning  that  osteomyelitis 
has  been  observed  as  a  sequel  of  angina,  identical  fungi 
being  demonstrated  in  the  tonsils  and  the  pus  contained 
in  the  bone-marrow.  The  most  typical  case  of  the  kind 
was  one  of  simple  fracture  of  the  hiunerus,  which  devel- 
oped symptoms  of  osteomyelitis  immediately  after  an 
intercurrent  attack  of  angina. 

Some  of  these  complications,  including  the  milder 
ones,  especially  simple  irritation  of  serous  membranes, 
are  probably  due  more  to  resorption  of  toxins  than  to  a 
true  metastatic  process.  The  same  pathogenesis  applies 
to  the  neuritis  which  sometimes  follows  simple  angina,  as 
well  as  pharyngeal  diphtheria,  and  has  been  more  fully 
described  elsewhere  (see  p.  60). 

Catarrh  and  suppuration  of  the  middle  ear 
frequently  complicate  inflammations  of  the  pharynx,  and 
have  already  been  described  (see  p.  28). 

After  a  number  of  attacks  of  lacunar  inflammation  a 
condition  of  atrophy  is  sometimes  produced  by  the  pro- 
liferation and  secondary  contraction  of  the  interstitial 
tissue ;  or,  more  frequently,  hyperplasia  results  from  the 
reactive  swelling  of  the  follicles.  This  subject  will  be 
discussed  more  in  detail  in  a  subsequent  section. 

The  treatment  of  an  acute  attack  of  angina  is  to  be 
based  on  the  principle  that  the  disease  is  a  general  infec- 
tion. The  local  measures  include  only  such  as  have  been 
found  by  experience  to  possess  the  power  of  allaying  the 
pain.  The  idea  that  the  process  can  be  aborted  or  even 
mitigated  by  means  of  local  antisepsis  is  wrong,  both  in 
theory  and  in  practice ;  antiseptic  applications  fail  to 
reach  the  true  seat  of  the  inflammation.     They  cannot  be 


140  APPENDIX. 

used  in  sufficient  strength  to  be  effective,  and  are  not 
witliout  danger  on  account  of  the  unavoidable  risk  of 
swallowing.  There  is  no  internal  antiseptic  capable  of 
cutting  short  the  attack,  although  several  such  substances 
are  brought  forward  every  year.  My  treatment  is,  there- 
fore, as  follows  : 

If  there  is  constipation,  I  immediately  order  a  laxative, 
consisting,  for  children,  in  a  small  dose  of  compound 
licorice  powder,  for  adults  either  in  some  remedy  that 
they  have  already  found  to  act  successfully  or  an  infusion 
of  senna.  The  patient  must  go  to  bed.  If  the  inflam- 
mation is  still  in  its  initial  stage,  he  is  given  several  cups 
of  chamomile  tea,  put  into  a  dry  pack  un|^il  profuse 
sweating  is  induced,  and  receives  1  gm.  (15  grains)  of 
salipyrin  twice  a  day  until  the  headache  and  pain  in  the 
limbs  have  disappeared.  This  requires  two,  or  at  most 
three,  days.     The   local   measures  are   simply  a   warm 


Fig.  23— (Half-size.) 

gargle  (30°  C — 86°  F.)  consisting  of  sage  tea  and  a  wet 
throat  compress  (Fig.  8,  p.  41). 

Complications  are  to  be  treated  according  to  general 
therapeutic  principles.  The  urine  is  to  be  examined  at 
frequent  intervals,  and  the  diet  restricted  to  semifluid, 
non-irritating  articles. 

The  only  effective  means  of  guarding  against  recurrence 
consists  in  removal  of  the  infectious  material  deposited  in 
the  dilated  crypts,  followed  by  free  incision.  Unless  the 
measures  indicated  in  hyperplasia  of  the  tonsils  and  de- 
scribed on  p.  154  are  to  be  employed,  the  lacunar  cavities 
are  laid  open  by  dividing  their  walls.  To  prevent  them 
from  growing  together  it  has  been  recommended  to  tear 
the  walls  with  a  blunt  instrument  like  a  strabismus  hook. 
It  is  better,  however,  to  use  a  smooth,  sharp  instrument 


CATARRH  AND  SUPPURATION  OF  MIDDLE  EAR.    141 

like  that  illustrated  in  Fig.  23,  both  because  it  inflicts 
less  pain  and  because  the  bands  of  cicatricial  tissue  which 
are  often  found  in  the  interior  of  the  crypts  are  more  certain 
to  be  divided.  The  parts  are  first  anesthetized ;  the 
position  of  the  various  ducts  determined  by  exploration 
with  a  strabismus  hook ;  the  knife  is  then  introduced  and 
withdrawn  from  behind  forward.  Hemorrhage  is  con- 
trolled by  means  of  a  cold  gargle. 

Similar  dilatations  in  the  adenoid  tissue  of  the  naso- 
pharynx, the  median  and  lateral  pharyngeal  recesses,  or 
so-called  bursa  pharyngea,  may  be  cauterized  with  a 
crystal  of  silver  nitrate  or  chromic  acid  fused  on  the  end 
of  a  probe.  The  field  of  operation  should  be  well  illu- 
minated by  means  of  the  head-mirror,  and  the  cavities 
obliterated  as  described,  or  curetted  out.  Kafemann's 
curet  may  be  recommended  for  this  purpose.  In  the  lin- 
gual tonsil  the  condition  is  extremely  rare ;  if  necessary, 
the  same  operation  is  applicable,  or  the  scissors  or  cold 
snare  may  be  used. 

Interstitial  disease,  ending  in  absceSS,  is  ranch  less 
common  than  lacunar  inflammation  of  the  essential  tissue. 
The  condition  is  usually  confounded  with  phlegmon  of 
the  pharynx,  a  much  more  common  affection  (see  p.  65). 
Indeed,  tonsillar  abscess  may  lead  to  phlegmon  of  the 
pharynx,  but  in  most  cases  it  is  strictly  limited  to  the 
original  adenoid  region. 

The  course  of  abscess  of  the  palatal  tonsil  is  marked  by 
similar  general  and  subjective  local  phenomena  as  that  of 
an  ordinary  angina.  The  dysphagia,  however,  is  compli- 
cated by  a  certain  limitation  of  the  movements  of  the 
jaws,  due  to  the  tension  of  the  tonsillar  capsule.  There 
is  little  redness,  and  what  there  is,  is  sometimes  confined 
to  the  affected  tonsil.  The  latter  is  very  much  swollen, 
however,  and  extremely  sensitive  to  the  touch,  the  surface 
is  smooth  or  slightly  irregular,  and  occasionally  covered 
with  a  little  purulent  or  fibrinous  exudate.  Rupture  of 
the  abscess  is  followed  by  disappearance  of  the  symptoms 


142  APPENDIX. 

and  the  liberation  of  pus  mixed  with  blood  or  necrotic 
fragments  of  tonsillar  tissue  which  give  it  a  grayish  and 
creamy  appearance.  Sometimes  the  abscess  is  evacuated 
only  through  one  of  the  crypts  near  its  upper  pole.  The 
improvement  in  the  symptoms  is  only  temporary,  and  is 
followed  by  renewed  accumulation  of  pus.  In  such  a 
case  the  surgeon  should  not  wait  for  spontaneous  rupture, 
but  should  take  his  probe  and  look  for  the  crypt  through 
which  the  abscess  can  be  most  readily  reached,  because  it 
is  also  the  one  through  which  infection  has  taken  place. 
The  wall  of  this  crypt  is  then  divided  with  a  knife,  ex- 
actly as  described  above.  If  spontaneous  rupture  fails 
to  take  place  and  the  abscess  finds  it  impossible  to  form 
a  sufficiently  large  opening  either  below  or  above  to  evac- 
uate its  contents,  a  chronic  tonsillar  abscess  is  produced. 
The  pus  accumulates  again  and  again,  giving  rise  to  a 
feeling  of  tension  and  a  nauseating  taste  in  the  mouth  ; 
the  tonsil  remains  swollen,  and  pus  is  discharged  from 
time  to  time — in  some  cases  several  times  a  day.  At  any 
time  the  pus  may  be  expressed  by  compressing  the  tonsil 
or  exerting  pressure  on  the  retromaxillary  region.  If 
the  abscess  has  not  extended  beyond  its  capsule,  simple 
division  of  the  walls  will  suffice  even  in  this  case.  If, 
however,  fistulous  tracts  have  already  been  formed  in  the 
surrounding  tissue,  it  may  be  necessary  to  divide  both  the 
peritonsillar  tissue  and  the  soft  palate.  This  must  be 
done  with  a  galvanocautery,  as  otherwise  a  furious  hemor- 
rhage results.  [The  author  makes  a  distinction,  and  a 
correct  one,  from  an  anatomic  standpoint,  between  supra- 
tonsillar  phlegmon  and  abscess  of  the  palatal  tonsil.  In 
the  former  the  pus  is  really  outside  the  tonsil  proper  and 
rather  in  the  circumtonsillar  connective  tissue ;  in  the 
latter  it  is  within  the  tonsillar  substance.  The  symptoms 
of  the  two  are  practically  the  same,  though  there  is  less 
bulging  of  the  faucial  pillars  in  the  latter. — Ed.] 

The  pharyngeal  tonsil  in  exceptional  cases  may  be  the 
seat  of  pathologic  processes  which  cannot  be  distinguished, 
especially  from  lacunar  inflammation,  without  rhinoscopy. 


CATARRH  AND  SUPPURATION  OF  MIDDLE  EAR.    143 

These  conditions  occur  both  independently  and  as  the 
result  of  inflammation  of  the  palatal  tonsil.  They  are 
always  complicated  by  intense  nasal  obstruction,  and  ter- 
minate by  evacuation  of  the  pus  through  the  nose.  Owing 
to  the  anatomic  relations  making  it  possible  for  the  pus 
to  be  discharged  in  a  downward  direction,  the  abscess 
always  heals  spontaneously. 

Abscess  of  the  lingual  tonsil,  in  spite  of  the  exposed 
position  of  that  structure,  is  even  more  difficult  to  dis- 
cover than  abscess  of  the  pharyngeal  tonsil,  to  which  the 
surgeon's  attention  may  at  least  be  called  by  the  presence 
of  nasal  obstruction.  From  the  small  number  of  cases 
that  have  been  observed  it  would  appear  that  the  tonsil 
becomes  greatly  swollen  and  reddened ;  the  surface  may 
be  covered  with  lacunar  deposits ;  the  base  of  the  tongue 
shares  in  the  inflammatory  process;  and  attention  is  usu- 
ally called  to  the  affected  region  by  the  unusual  severity 
of  the  dysphagia  and  the  absence  of  anything  abnormal 
in  the  pharynx. 

These  interstitial  inflammations  of  the  pharyngeal  ring 
acquire  a  peculiar  significance  through  their  complications, 
which  are  comparatively  frequent.  While  in  lacunar 
inflammation  metastasis  is  the  rule,  in  the  interstitial 
form  of  the  disease  pyemic  symptoms,  making  up  the 
picture  of  cryptogenetic  septicopyemia  or  metastatic  dis- 
ease of  the  heart,  are  occasionally  observed,  yet  poly- 
arthritis and  inflammations  of  serous  membranes  are 
practically  unknown.  Deep  abscesses  are  comparatively 
common.  They  may  occur  in  the  intermaxillary  fold ; 
or  along  the  lower  jaw  in  the  form  of  a  parulis  or  gum- 
boil, when  the  teeth  are  sound  ;  in  the  retromaxillary, 
nuchal,  and  retropharyngeal  regions;  and  even  in  the 
mediastinum  or  along  the  vertebral  column  as  far  down 
as  the  lower  extremities.  The  ultimate  fate  of  the  abscess 
is  variable.  A  cure  cannot,  of  course,  be  eflPected  without 
first  removing  the  original  focus. 

The  phlegmonous  affections  in  the  floor  of  the  mouth 
and  in  the  deep  layers  of  the  connective  tissue  of  the 


144  APPENDIX. 

neck  that  develop  secondarily  to  tonsillar  abscesses  have 
received  special  names,  and  are  described  at  length  in 
another  portion  of  this  work  (see  p.  66). 

To  prevent  recurrence,  the  infective  focus  should  be 
removed  by  laying  open  or  extirpating  the  hyperplastic 
portions  of  the  tissue. 

Hyperplasias  of  the  lymphatic  ring,  especially  of  the 
palatal  portion,  have  always  been  a  fruitful  field  for  the 
physician,  although  his  interference  has  not  always  been 
indicated.  The  condition  is  most  frequent  in  childhood. 
The  pharyngeal  tonsil  is  by  far  the  most  frequently 
affected ;  next  in  order  is  the  palatal  tonsil,  which  is 
affected  two-thirds  as  often ;  while  the  lingual  follicles 
are  least  frequently  affected,  and  practically  only  in  ad- 
vanced age.  [In  our  experience  this  condition  is  very 
frequent  in  women  from  thirty-five  to  fifty  years  of  age. 
—Ed.] 

When  "  adenoid  vegetations  "  and  hypertrophy  of  the 
tonsil  are  associated,  as  commonly  happens,  the  recent 
occurrence  of  some  disease  of  childhood  will  almost  always 
be  given  in  the  history.  The  children,  who  before  their 
attack  presented  nothing  abnormal,  present  the  character- 
istic symptoms  after  scarlet  fever,  measles,  diphtheria, 
or  sometimes  whooping-cough.  The  topical  leukocytosis 
that  always  occurs  in  these  diseases  leads  to  permanent 
hyperplasia  in  the  plastic  tissues  of  childhood.  Much 
less  commonly  the  cause  of  tlie  hyperplasia  is  found  in 
repeated  attacks  of  inflammation  of  the  pharyngeal  tonsil. 
In  the  former  mode  of  origin  the  surface  of  the  hyper- 
trophied  portions  presents  only  a  certain  wavy  irregularity 
without  other  change ;  in  the  latter  variety  the  remains 
of  the  inflammatory  process  are  always  found  in  the  form 
of  deep  lacunae,  inspissated  or  coalescent  masses  of  secre- 
tion, and  in  the  presence  of  small  cysts  (Plate  31,  Fig. 
3 ;  Plate  32,  Fig.  2)  on  the  surface,  produced  by  adhe- 
sions or  by  the  growing  together  of  the  epithelium  over 
the  clefts  remaining  in  the  gland  after  the  inflammatory 


HYPERPLASIAS.  145 

processes.  In  the  pharyngeal  tonsil  the  most  character- 
istic and  most  troublesome  conditions  of  this  kind  are 
found  in  the  median  and  lateral  recesses  (Plate  22,  Fig. 
1).  The  inflammatory  origin  of  these  structures  is  proved 
beyond  a  doubt  by  the  fact  that  they  occur  only  in  later 
years. 

A  general  hyperplasia  is  occasionally  accompanied  by 
the  presence  of  small,  sessile,  or  pedunculated  neoplasms, 
consisting  either  of  connective  tissue  or  of  epithelium. 

Hyperplasia  of  the  lingual  tonsil  is  observed  only  in 
adults,  and  may  present  all  the  symptoms  that  have  just 
been  described. 

Anatomically,  the  various  enlargements  of  the  tonsils 
are  found  to  consist,  in  the  main,  of  proliferation  and 
multiplication  of  the  lymph-follicles.  During  childhood, 
and  in  conditions  unattended  with  inflammation,  there  is 
very  little  interstitial  tissue  and  only  a  small  amount  of 
vascular  new  formation  observed,  while  in  persons  of 
more  advanced  age,  or  after  some  inflammatory  process, 
the  follicles,  owing  to  obliteration  of  connective  tissue,  be- 
come thick,  and  trabeculse  with  numerous  new  blood-ves- 
sels are  formed  (Plate  31,  Fig.  2).  Owing  to  the  irritation 
of  the  inflammatory  material  at  the  bottom  of  the  lacunar 
clefts,  the  epithelium  at  that  point  proliferates  and  forms 
large  masses;  sometimes  the  epithelium  on  the  surface 
also  becomes  thickened  and  converted  into  horny  strata. 

A  special  feature  of  enlargement  of  the  pharyngeal 
tonsil  is  the  presence  of  the  histologic  structures  charac- 
teristic of  tuberculosis,  without  the  exterior  of  the  tumor 
being  in  any  way  distinguished  from  other  forms  of  en- 
largement, there  being,  especially,  an  entire  absence  of 
ulceration.  Since  the  lymphatics  of  the  adenoid  ring 
represent  the  channels  by  which  tubercle  bacilli  reach 
the  maxillary  and  cervical  glands,  the  fact  that  the  latter 
present  a  scrofulous  appearance  cannot  be  utilized  to 
determine  whether  the  bacilli  are  the  cause  of  the  hyper- 
plasia, or  whether  they  have  invaded  the  hyperplastic 
tissue  secondarily.  It  may  be  that  it  is  this  infection 
10 


146  APPENDIX. 

that  is  responsible,  in  certain  cases,  for  the  recurrence 
of  the  tumor  after  operation ;  at  all  events  it  cannot  be 
distinguished  from  other  tumors  except  by  histologic 
examination. 

The  83nnptoms  of  hyperplasia  of  the  palatal  tonsils  are 
often  quite  insignificant  unless  the  inHamniatory  recurrences 
that  have  been  mentioned  make  their  appearance.  Dur- 
ing the  intervals  between  the  inflammatory  attacks  little 
is  to  be  seen,  as  the  enlargement  is  only  moderate ;  but 
in  severer  grades,  when  the  tonsils  are  in  contact  and 
even  when  the  tissues  are  at  rest,  or  at  least  during  the 
act  of  deglutition,  speech  becomes  nasal,  owing  to  the 
insufficient  action  of  the  soft  palate,  and  the  voice,  owing 
to  the  interference  with  the  movements  of  the  tongue, 
sounds  as  though  the  individual  were  speaking  with  his 
mouth  full.  The  swallowing  of  large  morsels  of  food 
gives  considerable  pain,  and  the  mechanical  interference 
with  the  act  of  deglutition  often  causes  the  ingesta  to 
regurgitate  into  the  larynx  or  through  the  nose. 

Enlargement  of  the  lingual  tonsil  produces 
symptoms  of  a  more  "  nervous "  character.  It  is  not 
uncommon  that  a  diagnosis  of  hysteria  or  neurasthenia 
is  made  when  an  irritative  cough  has  existed  for  years 
without  any  laryngeal  or  pharyngeal  conditions  being 
found,  although,  as  a  matter  of  fact,  the  epiglottis  is 
constantly  being  irritated  by  the  enlarged  lingual  ton- 
sils, which  cannot  be  seen  in  an  ordinary  examination 
of  the  throat.  On  the  other  hand,  the  epiglottis  may  be 
wedged  underneath  the  adenoid  tissue  and  produce  a 
reflex  irritation  in  that  way.  In  addition,  the  patients 
often  complain  that  they  feel  as  if  there  were  a  foreign 
body  in  the  throat ;  as  if  tiiey  had  swallowed  a  fish-bone ; 
or  they  describe  the  well-known  "globus  hystericus," 
which  has  always  been  regarded  as  characteristic  of  hys- 
teria. These  abnormal  sensations,  as  is  always  the  case 
in  diseases  of  the  throat,  are  often  referred  to  situations 
far  removed  from  the  point  of  irritation.  From  what 
has  been  said  in  the  section  on  General  Symptomatology, 


ENLARGEMENT  OF  THE  LINGUAL  TONSIL.     147 

it  follows  that  the  sensory  irritation  and  motor  reflexes 
may  exert  their  influence  in  regions  far  remote  from  the 
seat  of  the  disease. 

It  is  thus  seen  tliat  the  symptoms  of  hyperplasia,  both 
of  the  palatal  and  of  the  lingual  tonsil,  present  nothing 
that  is  characteristic,  and  the  diagnosis  practically  has 
to  be  made  by  direct  visual  examination. 

The  case  is  different  with  the  pharyngeal  tonsil. 
One  who  has  had  any  experience  at  all  can  draw  his 
deductions  from  the  history  alone  and  from  the  general 
symptoms.  A  child  of  six  to  twelve  years  is  brought  for 
examination.  The  parents  think  there  must  be  something 
in  the  child's  nose  because  it  often  keeps  its  mouth  open, 
is  unable  to  blow  its  nose,  and  "  is  always  full  of  mucus." 
On  examination,  it  is  found  that  the  mouth  as  a  matter 
of  fact  stands  open,  the  chin  hangs  down,  the  nasolabial 
folds  are  obliterated,  and  the  whole  appearance  of  the 
face  is  dull,  and  often  absolutely  idiotic  (see  Fig.  24). 
The  upper  lip  may  be  somewhat  swollen,  the  retromaxil- 
lary  and  inframaxillary  glands  are  often  enlarged,  and 
the  picture  of  "  scrofulosis "  is  completed  by  the  pale 
and  somewhat  bloated  appearance.  The  nose  is  exam- 
ined because  the  patient  complains  of  obstruction,  and 
nothing  is  found  to  explain  the  interference  with  respi- 
ration. The  inferior  and  middle  meatus  are  quite  free ; 
it  is  even  possible  to  see  the  posterior  wall  of  the  phar- 
ynx. The  only  inference  is  that  there  must  be  some 
"other  obstruction.  Another  careful  examination  is  made, 
and  the  patient  is  asked  to  swallow.  It  is  found  that 
the  parts  about  the  pharynx  remain  quite  immovable. 
In  another  case  the  choanje  appear  unusually  wide,  and 
from  the  upper  margin  a  smooth,  somewhat  wavy  struc- 
ture is  seen  protruding  into  the  lumen  (Plate  20,  Fig.  2). 
In  both  of  these  cases,  which  it  must  be  admitted  are  not 
so  very  common,  the  cause  of  the  stenosis  may  be  directly 
seen.  In  the  first  case  it  is  the  pharyngeal  tonsil  hang- 
ing down  behind  the  choanae  like  a  curtain,  and  obscuring 
the  movements  of   Passavant's   fold  and  of  the   tubes 


148 


APPENDIX. 


Fig.  24.— Characteristic  appearance  in  pharyngeal  tonsil. 


ENLARGEMENT  OF  THE  LINGUAL  TONSIL.     149 

during  deglutition ;  in  the  second  it  is  an  adenoid  vege- 
tation of  moderate  size,  the  lower  margin  of  which  is 
visible. 

Slight  enlargements  of  the  pharyngeal  tonsil,  which  may 
not  be  visible  although  it  is  quite  possible  to  see  through 
the  nasal  meatus,  may  produce  a  good  deal  of  nasal  ob- 
struction if  they  are  situated  in  the  fornix,  so  as  com- 
pletely to  arrest  the  physiologic  air-current  at  the  point 
where  it  comes  in  contact  with  the  upper  wall  of  the 
pharynx  and  is  deflected  downward  (see  p.  16). 

In  most  cases,  however,  the  conditions  are  somewhat 
different :  the  lower  turbinates  are  pale  and  greatly  thick- 
ened, especially  in  front ;  the  inferior  nasal  meatus,  par- 
ticularly in  the  median  enlargement  of  the  floor  of  the 
nose,  contains  numerous  gray  and  yellow  masses  of  mucus, 
or  possibly  a  few  drops  of  pus — very  rarely  dry  crusts. 
The  breath  has  a  peculiar,  musty  odor,  due  to  the  decom- 
position of  secretions  in  the  mouth. 

The  oblique  or  transverse  position  of  the  incisors  and 
canines  is  often  quite  noticeable.  Sometimes  individual 
teeth  are  found  directly  behind  their  neighbors,  for  they 
have  no  other  room  to  grow,  as  the  lower,  and  particu- 
larly the  upper,  jaw,  is  compressed  laterally ;  the  palate  is 
high,  and  suggests  the  shape  of  a  church  roof.  When  the 
tongue  is  depressed  and  the  soft  palate  contracted  by  the 
reflex  choking  which  ensues,  a  thick  mass  of  mucus  is 
seen  to  glide  down  the  posterior  wall  of  the  pharynx. 
This  sign  is  practically  pathognomonic  of  adenoid  vege- 
tations in  children.  Owing  to  the  inadequate  ventilation 
or  complete  absence  of  ventilation,  the  masses  of  tenacious 
mucus  produced  by  constantly  secreting  follicular  and 
glandular  tissues  are  unable  to  escape,  and  accumulate  in 
the  pharynx.  They  are  identical  with  the  mucus  that  we 
have  already  seen  deposited  in  the  anterior  of  the  nose. 
In  exceptional  cases  the  lower  extremity  of  the  tumors 
attached  to  the  posterior  wall  is  seen  to  project  beneath 
the  soft  palate. 

In  the  cases  described  so  far  the  symptoms  which  called 


150  APPENDIX. 

the  parents'  attention  to  the  seat  of  the  trouble,  and  natu- 
rally directed  the  physician's  examination  to  the  proper 
point,  were  all  referred  to  the  nose.  This  is  not  always 
the  case ;  sometimes  the  physician  is  consulted  on  account 
of  deafness  said  to  have  developed  within  a  Meek.  The 
ear  is  examined,  although  the  little  patient's  face  may 
already  have  given  us  an  inkling  of  the  state  of  aifairs, 
because  it  is  better  to  secure  the  parents'  cooperation,  and 
there  we  see  a  pale,  somewhat  retracted,  or  possibly 
opaque  drum-head  without  the  slightest  sign  of  irritation. 
We  find  the  hearing  reduced,  often  to  an  alarming  extent, 
so  that  the  whispered  voice  can  be  heard  only  at  a  dis- 
tance of  10  cm.,  or  there  may  be  an  obstinate,  possibly  a 
fetid,  suppuration,  without  any  signs  of  bone-disease,  or 
perhaps  associated  with  bone-disease.  In  the  first  case 
that  we  have  supposed,  adenoid  vegetations  are  present 
almost  beyond  a  doubt,  for  only  "  congenital "  or  syph- 
ilitic stenosis  of  the  tubes — both  extremely  rare  condi- 
tions— can  produce  such  symptoms  in  children.  In  the 
second  case  it  is  absolutely  necessary  to  look  for  the  ade- 
noid vegetations,  for  the  otitis  has  either  been  produced 
by  the  introduction  of  some  of  the  infectious  material  that 
fills  the  nasopharynx  or  it  is  kept  up  by  the  passage  of 
such  material  and  by  the  insufficient  tubal  ventilation. 

Let  us  take  another  example.  A  clinical  history 
reads  somewhat  as  follows :  The  mother  has  often  told 
the  family  physician  that  her  nine-year-old  boy  is  con- 
stantly troubled  with  headaches.  During  the  summer- 
time the  headache  was  attributed  to  the  heat ;  during  the 
fall,  to  the  extra  tax  on  his  brain  incident  to  the  begin- 
ning school-work ;  and  during  the  winter  it  was  supposed 
that  the  headache  was  probably  due  to  the  long  confine- 
ment indoors,  which  isn't  good  for  anybody.  However, 
the  warm  days  of  spring  arrive,  and  although  the  family 
goes  away  for  a  week's  change  of  air  at  Easter,  and  some 
improvement  is  noted,  there  is  no  radical  change  in  the 
child's  condition.  The  boy  looks  tired  and  pale — perhaps 
he  has  grown  somewhat  rapidly,  so  we  will  give  him  iron. 


ENLARGEMENT  OF  THE  LINGUAL  TONSIL.     151 

But  his  condition  does  not  improve.  In  spite  of  careful 
examination  no  good  reason  can  be  found  for  this  nervous 
headache.  There  is  no  tape-worm,  no  well-founded  sus- 
picion of  masturbation,  nor  any  other  reasonable  cause. 
What  is  to  be  done  ?  Don't  send  your  patient  to  a  spa ; 
don't  keep  him  out  of  school  for  six  months ;  don't  keep 
on  doctoring ;  especially,  don't  brand  the  poor  little  chap 
as  a  malingerer.  The  only  proper  thing  to  do  is  to  ex- 
amine him.  Examine  him,  and  examine  him  for  adenoids. 
Not  only  nine  out  of  ten  times,  but  forty-nine  out  of  fifty 
times,  adenoids  will  be  found.  It  not  only  means  a  free- 
dom from  present  troubles  to  the  little  patient,  but  in 
many  cases  the  saving  of  his  health  and  career  for  life. 
The  true  cause  of  these  juvenile  headaches  is  often  over- 
looked, because  the  general  appearance  does  not  at  all 
correspond  to  the  type  that  has  been  described,  the  hyper- 
plasia having  developed  during  the  later  years  of  child- 
hood on  a  congenital  foundation  and  aft«r  some  intervening 
disease — too  late,  therefore,  to  impress  upon  the  patient's 
features  the  characteristic  appearance. 

On  the  other  hand,  the  cause  is  more  readily  found  in 
another  group  of  cases  in  which  the  anxious  father,  after 
punishment  and  extra  work  at  home  have  equally  failed 
to  keep  the  boy  up  in  his  school-work,  is  told  by  the 
teacher  that  he  has  noticed  the  icant  of  concentration  in  the 
boy,  who  at  other  times  may  be  quite  attentive  and  is  gen- 
erally well  behaved.  When  he  is  called  up  he  starts  as  if 
he  were  frightened  out  of  sleep,  can't  collect  his  thoughts, 
forgets  everything  in  a  very  short  time,  and  is  absolutely 
unable  to  concentrate  his  attention  on  one  subject  for  any 
length  of  time.  The  latter  symptom,  known  under  the 
name  of  "  aprosexia,"  has  been  found  to  be  particularly 
characteristic  of  enlargement  of  the  pharyngeal  tonsil. 
[This  term  has  been  overworked.  There  is,  indeed,  a 
true  aprosexia,  but  many  cases  reported  under  this  cate- 
gory have  shown  by  their  subsequent  course  that  the  lack 
of  mental  attention  has  been  due  solely  to  deafness. — Ed.] 
It  occurs  chiefly  when  the  tumor  is  large  and  develops 


152  APPENDIX. 

early,  and  is,  therefore,  usually  combined  with  the  typical 
facial  expression.  This,  with  its  vacant  stare,  corresponds 
perfectly  with  the  psychic  abnormality  and  is  due  in  the 
main  to  stagnation  of  the  lymph  at  the  base  of  the  skull, 
which  always  accompanies  the  presence  of  large  adenoids 
(see  p.  18).  This  aprosexia,  from  the  frequency  of  its 
occurrence,  always  calls  for  an  examination,  even  in  the 
absence  of  other  less  important  psychic  symptoms. 

Examination  is  always  necessary  to  justify  an  operation, 
even  when,  as  has  been  described  above,  the  hypertrophied 
tissues  are  plainly  visible  through  the  nose.  It  not  only 
enables  one  to  plan  the  operation  accurately,  but  is,  in 
addition,  indispensable  for  purposes  of  diagnosis,  for  it 
occasionally  happens  that  a  part  at  least  of  the  above- 
described  symptoms  are  produced  by  some  other  cause, 
such  as  tumors  of  a  different  character,  disease  of  acces- 
sory sinuses,  congenital  abnormality,  rachitis,  imbecility, 
and  the  like. 

In  the  case  of  adults  even  greater  caution  is  necessary. 
In  them  headache  is  much  more  often  due  to  other  causes, 
acting  either  within  or  without  the  nose,  pharyngeal 
secretion  depending  not  only  on  pharyngeal,  but  more 
commonly  on  nasal,  or  rather  perinasal,  disease. 

These  are  the  most  conspicuous  and  most  important 
conditions  ;  they  do  not,  however,  exhaust  the  list  of  ])os- 
sible  sequelae.  Fig.  24  shows  a  deformity  of  the  thorax 
which  is  not  infrequent  in  the  disease  under  discussion, 
and  consists  in  retraction  of  the  lower  true  ribs  opposite 
the  line  of  attachment  of  the  diaphragm.  The  deformity 
is,  therefore,  aptly  termed  "  diapliragmatic  furrow."  Its 
production  is  due  to  the  fact  that  the  inspiratory  tension 
of  the  diaphragm  is  not  compensated  for  want  of  the 
amount  of  air  necessary  to  distend  the  inferior  portions 
of  the  lungs,  the  pull  of  the  muscle  causing  retraction 
of  the  ribs,  which,  in  children,  are  soft  and  yielding  and 
sometimes  rachitic.  The  deficient  ventilation  can  also 
be  determined  by  percussion  at  the  apices,  and  is  an 
important  factor  in  producing  or  keeping  up  the  ominous 


ENLARGEMENT  OF  THE  LINGUAL  TONSIL.     153 

apical  catarrh — in  other  words,  tuberculosis.  When,  on 
the  otlier  hand,  there  is  h  tendency  to  emphysema  or 
mild  grades  of  emphysema  exist,  the  evil  is  aggravated 
by  mouth-breathing,  which  affects  expiration  quite  as 
much  as  inspiration,  and  by  the  stasis  that  is  always 
present  to  a  greater  or  less  degree  in  the  pulmonary 
tissue. 

Even  in  cases  in  which  these  grave  symptoms  are  not 
observed  the  insufficient  oxygenation  is  indicated  by  the 
anemic  and  bloated  appearance  of  the  children ;  and  the 
evil  influence  on  the  general  health  is  increased  by  the 
decomposition  of  the  secretions  which  are  constantly 
swallowed. 

It  should  be  especially  emphasized  that  the  phenomena 
of  nasal  enuresis  and  nasal  epilepsy  referred  to  in 
the  general  portion  of  this  work  (see  p.  27)  are  chiefly 
due  to  adenoid  vegetations. 

During  the  examination  the  patient  should  be  placed 
on  a  chair  in  such  a  way  that  his  mouth  is  at  the  same 
level  as  the  examiner's  eye.  Little  children  should  be 
held  by  the  mother  or  other  attendant,  who  holds  the 
child's  legs  between  her  knees,  but  only  lightly,  so  as  to 
avoid  provoking  resistance  at  the  very  beginning  of  the 
examination.  The  child's  cheeks  should  be  touched  with 
the  tongue  depressor  and  with  the  mirrors  to  show  that 
they  do  not  cut,  and  he  may  even  be  allowed  to  use  the 
mirror  himself.  Children  that  are  at  all  tractable  will 
usually  allow  themselves  to  be  examined  at  once. 

Unless  there  is  a  good  deal  of  mucus,  the  nasopharynx 
can  be  readily  seen.  •  Several  sizes  of  tumor  may  be  dis- 
tinguished for  the  sake  of  simplicity  as  follows — First 
grade  :  The  tumor  does  not  extend  down  to  the  upper 
border  of  the  choanse.  Second  grade  :  The  tumor  blocks 
the  nasopharynx  down  to  the  choanae.  Third  grade  :  The 
tumor  encroaches  on  the  opening  of  the  choanae.  If  it 
is  found  impossible  to  see,  palpation  must  be  resorted  to, 
as  described  on  page  35.     It  is  a  characteristic  sign  that 


154  APPENDIX. 

the  finger  is  always  stained  with  blood  when  it  is  with- 
drawn, as  the  pharyngeal  tonsil  is  very  easily  torn. 
During  palpation  the  presence  of  hyperplasia  on  the 
posterior  wall  must  incidentally  be  noted,  because  the 
latter  cannot  be  felt  with  the  instrument. 

The  treatment  of  hyperplasia  of  the  tonsils  must  always 
be  surgical.  Local  applications,  cauterization,  and  simi- 
lar measures  are  absolutely  useless.  Operation  on  the 
palatal  tonsil  is  indicated  in  the  presence  of  recurring 
attacks  of  angina  and  their  complications  or  sequelae, 
revealing  a  constant  focus  of  infection  which  is  found 
by  inspection  in  the  lacerated  tonsil,  and  when  the  en- 
largement is  so  great  as  to  interfere  with  swallowing. 
Ablation  of  the  lingual  tonsil  is  indicated  when  the  above- 
described  symptoms  are  present.  In  children  adenoid 
vegetations  of  any  size  must  always  be  removed,  because 
the  consequences,  especially  the  deafness,  while  they  may 
not  be  marked  at  the  time,  rarely  fail  to  make  their  aj)- 
pearance  later,  when  it  may  be  too  late  to  correct  them. 

At  a  more  advanced  age  thorough  clearing  out  of  the 
nasopharynx  is  usually  done  as  a  preliminary  measure 
for  the  relief  of  pharyngeal  symptoms,  particularly  insuf- 
ficient ventilation,  as  well  as  in  the  treatment  of  sequelae 
within  the  nose  or  independent  nasal  affections,  such  as 
hyperplasia  of  the  turbinates  and  inflammations  of  acces- 
sory sinuses.  Even  in  older  children  the  extirpation  of 
adenoid  vegetations  is  indicated  only  in  the  presence  of 
sequelae,  since,  if  the  latter  are  absent,  there  is  some 
reason  to  expect  involution  of  the  tumor,  which  usually 
takes  place  after  adolescence. 

A  small  tumor  in  an  adult  need  not  be  extirpated 
unless  its  evil  influence  on  some  other  condition  is  clearly 
established.  Patients  in  the  initial  stage  of  phthisis,  who 
suffer  from  insufficient  nasal  ventilation,  may,  therefore, 
be  treated  in  this  way. 

Small  palatal  tumors  that  are  badly  ulcerated  and  can- 
not be  readily  seized  with  the  instrument  can  be  treated 
only  by  opening  up  the  crypts,  as  described  on  page  140. 


ENLARGEMENT  OF  THE  LINGUAL  TONSIL.     155 

Lingual  tonsils  in  the  same  condition  must  be  cauterized 
with  trichloracetic  acid  or  the  galvanocautery  if  they  give 
trouble  ;  but  larger  tumors  of  this  kind  and  all  pharyngeal 
adenoid  tumors  must  be  extirpated.  To  remove  the  lin- 
gual tonsil  either  the  cold  or  the  galvanocaustic  snare  may 
be  used.  For  ordinary  tonsillotomy  the  old  Mathieu's 
tonsillotome  is  still  the  best.  It  enables  the  operator  to 
avoid  the  dangerous  accident  of  dividing  the  capsule  at 
the  point  where  it  is  pierced  by  the  tonsillar  artery,  since 
the  section  represents  the  cord  of  the  arc  formed  by  the 
capsule.  If  the  knife  is  used  and  the  tonsil  is  drawn 
inward  with  Muzeux's  hooks,  there  is  much  more  danger 
of  striking  the  capsule  ;  while  with  tonsillotomes  that  act 
by  compression  and  not  by  traction,  like  Mackenzie's  and 
similar  instruments,  there  is  also  a  risk  of  dragging  the 
tonsil  too  far  forward.  It  follows,  therefore,  that  the 
tonsil  is  not  to  be  removed  altogether,  since  we  anxiously 
avoid  dragging  out  the  external  middle  pole.  [A  less 
conservative  view  is  taken  in  this  country  regarding  the 
removal  of  the  entire  tonsil.  Strenuous  objection  has 
been  made  by  more  than  one  American  authority  against 
defining  a  tonsillotome  as  "  an  instrument  for  removing 
part  of  the  tonsil."  Most  operators  endeavor  to  remove 
as  much  of  the  organ  as  possible.  The  more  complete 
the  removal  is,  the  less,  naturally,  is  the  probability  of 
reenlargement.  In  proportion  to  the  whole  number  of 
operations,  alarming  hemorrhage  is  extremely  rare.  Great 
care  should  be  taken  to  see  that  the  faucial  pillars  are  not 
adherent  to  the  organ.  With  this  precaution  there  is 
very  little  danger  of  wounding  the  anterior  pillars,  an 
accident  largely  responsible  for  excessive  bleeding. — Ed.] 
Hence  there  is  a  possibility  that  the  portion  left  behind 
may  enlarge,  in  rare  cases  even  to  its  original  size,  a  point 
to  which  the  patient's  attention  should  be  called  at  the 
beginning.  It  is  a  good  rule  to  observe  caution  in  the 
matter  of  ])rognosis  in  anything  connected  with  the 
pharyngeal  ring.  The  symptoms  attributed  to  the  lingual 
tonsil  often  depend  not  only  on  the  local  irritation,  but 


166  APPENDIX. 

also  on  a  general  neurasthenic  basis,  and  the  alterations 
accompanying  "  adenoid  tumors,"  such  as  intranasal  swell- 
ings and  excessive  nasal  secretion,  may  be  due  to  other 
causes.  Besides,  although  the  operation  may  have  been 
quite  thorough,  the  tissue  left  behind  is  capable  of  grow- 
ing, and  in  very  rare  cases  does  actually  undergo  pro- 
liferation, so  that  while  there  is  every  reason  to  advise 
the  operation,  as  soon  as  its  necessity  has  been  recognized, 
the  patient  should  be  distinctly  informed  of  these  facts. 

Tonsillotomy  can  almost  always  be  performed  without 
anesthesia,  even  without  cocainization,  which  should  be 
avoided  because  the  reactive  engorgement  of  the  blood- 
vessels that  follows  cocainization  is  very  apt  to  produce 
a  marked  secondary  hemorrhage.  The  usual  hemorrhage, 
amounting  to  from  50  to  100  c.c.  (say  1.5  to  3  ounces), 
ceases  entirely  after  a  few  minutes,  or  at  most  requires  a 
little  mild  gargling  with  cold  water.  The  extremely  rare 
accident  of  hemorrhage  from  the  tonsillar  artery  can  be 
controlled  by  direct  compression  with  a  finger  or  with  a 
cotton  pledget  held  in  a  dressing  forceps,  or  by  compres- 
sion of  the  external  carotid.  Mikulicz  has  devised  a 
special  forceps  by  means  of  which  permanent  internal  and 
external  compression  can  be  applied. 

To  diminish  the  pain  after  the  operation,  the  wound 
may  be  dusted  with  orthoform  after  the  hemorrhage  has 
ceased.  The  only  after-treatment  required  is  regulation 
of  the  diet,  which  should  be  tepid,  soft,  and  bland,  and 
regular  gargling  after  each  meal.  As  the  wound,  like 
any  other  wound  in  the  mouth,  soon  becomes  covered 
with  a  yellowish  crust  of  fibrin,  the  patient  should  be 
informed  at  once  that  it  is  not  diphtheria. 

Extirpation  of  the  pharyngeal  tonsil  differs  from  an  ordi- 
nary tonsillotomy  in  that  it  includes  complete  removal  of 
the  foreign  tissue.  The  structure,  which  under  normal 
conditions  undergoes  complete  involution,  is  of  no  physi- 
ologic importance  whatever ;  its  radical  extirpation  is 
imattended  by  danger  and  is  all  the  more  necessary  as 
portions  that  are  left  behind  in  a  superficial  operation 


ENLARGEMENT  OF  THE  LINGUAL  TONSIL.     157 

very  frequently  undergo  proliferation,  and  as  the  symp- 
toms which  may  be  produced  by  a  comparatively  small 
tumor  in  the  fornix  or  at  the  tubal  fold  continue  just  as 
bad  as  before. 

Owing  to  the  comparatively  wide  distribution  of  the 
various  portions  of  the  tumor  on  the  upper  and  posterior 
lateral  walls  of  the  nasopharynx  and  on  the  arch  of  the 
fornix,  complete  removal  at  one  stroke  is  absolutely  im- 
possible. Although  with  a  suitable  instrument  a  tumor  the 
size  of  that  represented  in  the  accompanying  illustration 
(Fig.  25)  may  be  removed  at  one  sweep,  there  will  usually 


Fig.  25.— Hyperplastic  pharyngeal  tonsil  (natural  size). 

be  enough  tissue  left  behind  to  require  a  second  inter- 
ference. For  this  reason,  while  adults  may  be  operated 
on  without  anesthesia,  children  practically  always,  with 
the  exception  of  the  very  rarest  cases,  require  a  general 
anesthetic. 

The  author  long  ago  gave  up  the  practice  of  having 
the  children  held  by  force  and  attempting  to  perform  the 
operation  under  these  unpleasant  circumstances,  as  the 
results  are,  as  a  rule,  anything  but  satisfactory.  After 
anesthesia  has  been  induced,  the  child's  trunk  is  raised 
and  the  head  placed  on  a  roller  pillow.  No  mouth-gag 
need  be  used,  a  depressor  sufiBcing  to  keep  the  mouth  open. 


158  APPENDIX. 

The  instrument  recommended  for  the  operation  is  Gott- 
steiu's  knife.  The  degree  of  curvature  in  the  original 
instrument  is  insufficient  to  enable  the  operator  to  reach 
the  upper  wall  of  the  pharynx,  because  the  necessary  de- 
pression of  the  handle  is  prevented  by  the  teeth  of  the 
lower  jaw,  and  the  straight  surface  of  the  latter  also  inter- 
feres with  the  introduction  of  the  instrument  into  the  con- 
cave fornix.  The  author  is  therefore  in  the  habit  of  using 
a  knife  with  a  double  curve,  one  in  the  blade  and  one  in 
the  handle.  In  addition  it  has  the  lateral  bend  recom- 
mended by  Schrotter  for  laryngeal  instruments  (not  visible 
in  this  illustration),  which  leaves  the  view  unobstructed, 
and  finallv  a  shoulder  to  support  the  back  of  the  index- 
finger  (Fig.  26). 

To  introduce  the  instrument  into  the  mouth  it  must 
be  held  like  a  pen.  Great  care  is  necessary  to  avoid 
injuring  or  dividing  the  uvula,  an  accident  that,  to  the 
author's  knowledge,  has  occurred.  The  instrument  is 
then  seized  with  the  entire  hand  and  introduced,  first  on 
the  left-hand  side  in  front  of  the  nasopharyngeal  cavity, 
which  is  recognized  by  the  increased  resistance.  The 
edge  of  the  instrument  is  firmly  applied  and  brought 
down  along  the  upper  wall  of  the  pharynx.  The  same 
movement  is  then  repeated  on  the  right-hand  side.  The 
instrument  is  at  once  withdrawn,  and  at  the  same  instant 
the  attendant  turns  the  child  on  its  right  side,  face  down. 
The  surgeon  during  the  operation  stands  at  the  child's 
right  side.  As  the  anesthesia  by  this  time  has  partially 
subsided,  the  child  at  once  begins  to  cough  and  cry,  and 
this,  with  the  position,  suffices  to  prevent  aspiration  of 
blood  into  the  air-passages,  and  the  ablated  fragment  of 
tissue,  if  it  is  not  brought  out  with  the  instrument,  is  at 
once  ejected.  Sometimes  it  is  swallowed  or  it  gets  into 
the  nose  and  must  be  extracted,  or  the  chikl  must  be 
made  to  blow  it  out.  Occasionally  it  remains  adherent 
to  the  posterior  wall  by  a  shred  of  mucous  membrane. 
In  such  a  case  it  is  to  be  at  once  removed  with  forceps 
or  scissors. 


ENLARGEMENT  OF  THE  LINGUAL  TONSIL.     159 


More  of  the  auesthetic  is  then  given,  and  the  pos- 
terior wall  of  the  pharynx  curetted  with  an  ordinary 
Gottstein  knife,  after  which  the  surface  is  carefully  pal- 
pated while  the  child  is  still  under  the 
anesthetic.  In  almost  every  instance  a 
shred  of  tissue  will  be  found  that  needs 
removal;  if  necessary,  a  tonsillotomy 
may  be  performed  at  the  same  time. 
[The  combined  use  of  nitrous  oxid  gas 
and  a  little  ether  renders  it  unnecessary 
to  give  an  additional  dose  of  the  anes- 
thetic. A  skilful  administrator  can  de- 
termine at  will  the  length  of  the  period 
of  unconsciousness  after  the  withdrawal 
of  the  anesthetic,  and  can  with  perfect 
safety  make  this  period  amply  long 
enough  for  all  the  manipulations  des- 
cribed.— Ed.]  The  after-treatment  con- 
sists solely  in  seeing  that  the  child  blows 
its  nose  properly  (see  p.  22).  Irriga- 
tions and  measures  of  that  kind  are  to 
be  avoided,  and,  in  fact,  explicitly  for- 
bidden. 

Secondary  hemorrhage  is  always  due  to 
improper  technic.  [We  cannot  agree  with 
this  strong  statement.  Hemorrhage  has 
happened  in  the  experience  of  the  most 
skilful  operators,  and  is  by  no  means  un- 
common, as  the  perusal  of  the  literature 
of  the  last  five  years  will  amply  show. 
Incomplete  removal,  however,  is  doubt- 
less one  of  its  most  frequent  causes. — 
Ed.]  Either  one  of  the  tubal  folds  has 
been  injured,  especially  when  one  of  the 
instruments  invented  for  lateral  curet- 
ment  has  been  used,  or  the  ablation  has 
not  been  thorough,  the  tumor  having  merely  been  lacer- 
ated  instead  of  completely   removed.     In   such  a  case 


Fig.   26.— Gottstein's 
knife  (half  size). 


IGO  APPENDIX. 

the  operation  must  be  completed  at  another  sitting.  The 
rare  condition  of  hemophilia,  which  can  be  determined 
before  operation  is  decided  upon,  need  not  be  discussed 
in  this  connection.  (For  general  directions  in  regard 
to  arresting  hemorrhage  consult  p.  42.)  If  the  opera- 
tion is  performed  witliout  anesthesia,  all  the  steps  just 
described  will,  of  course,  not  be  necessary.  In  such 
a  case,  if  final  palpation  has  not  been  performed,  the 
patient  must  be  examined  after  ten  or  fourteen  days, 
which  is  the  time  required  for  the  clot  and  reactive 
swelling  to  disappear.  In  almost  every  instance  con- 
siderable remains  of  tissue  will  be  found  that  need  re- 
moval, and  the  surgeon  will  convince  himself  that  with- 
out this  careful  examination  the  operation  must  always 
be  incomplete. 

More  or  less  related  to  the  pharyngeal  tonsil  is  the 
peculiar  form  of  tumor  described  as  fibroma  of  the  naso- 
pharynx, fibroid  of  the  base  of  the  skull,  or  retromaxil- 
lary  polypus,  and  for  which  the  author  has  suggested  the 
term  juvenile  sarcoma  of  the  nasopharynx.  The 
tumor  occupies  the  upper  wall  of  the  pharynx — the  ba- 
silar fibrocartilage ;  it  occurs  chiefly  before  and  during 
puberty,  aud  in  boys.  Histologically,  and  so  far  as  ab- 
sence of  glandular  infection  or  metastasis  is  concerned, 
the  tumors  are  benign.  Clinically,  however,  they  may, 
as  appears  from  a  few  cases,  become  malignant  by  their 
continuous  growth,  which  produces  fatal  destruction  in 
the  important  organs  situated  in  this  region.  The  pecu- 
liar feature  of  these  tumors  is  that  in  a  large  proportion 
of  the  cases  they  undergo  spontaneous  involution  after 
puberty.  This  peculiarity  strongly  suggests  the  hyper- 
plasia of  the  pharyngeal  tonsil,  which  also  undergoes 
involution  after  puberty,  develops  at  the  same  site,  and 
resembles  them  in  structure.  It  is  true  that  the  greater 
portion  of  the  tumor  consists  of  firm  connective  tissue 
with  short  fibers,  but  the  delicate  blood-vessels  and 
islands  of  spheric  lymph-corpuscles  (Plate  32,  Fig.  3) 
strongly  suggest  the  picture  of  adenoid  tumors  in  later 


ENLARGEMENT  OF  THE  LINGUAL  TONSIL.     161 

life.  It  woiikl  appear  as  if  the  new  formation  of  con- 
nective tissue  accompanying  the  process  of  involution 
had  taken  on  a  progressive  atypical  character. 

Clinically,  the  tumor  betrays  its  nature  only  when  it 
begins  to  undergo  rapid  development,  sending  processes 
into  the  mesopharynx,  the  nose,  later  into  every  nook 
and  cranny  of  the  adjoining  tissues,  the  pterygopalatine 
fissure,  the  sphenomaxillary  fossa,  the  orifices  of  the 
accessory  sinuses,  and  the  orbits.  Ultimately  it  invades 
the  adjoining  bones,  not  by  infiltration,  but  by  the  press- 
ure of  its  growth,  enters  the  cavity  of  the  skull,  and 
brings  about  a  fatal  termination.  The  surface  of  the 
tumor  is  smooth,  of  a  dull  luster,  slightly  wavy  (Plate 
26,  Fig.  3),  and  often  marked  by  traumatic  erosions  and 
tissue  defects. 

The  symptoms,  of  course,  vary  greatly  according  to  the 
stage  of  the  growth.  Total  nasal  obstruction  is  always 
present ;  later  irregular  swellings  appear  in  various  por- 
tions of  the  face  and  of  the  maxillocervical  region ;  still 
later  blindness  and  deafness  may  develop.  A  certain 
dulness  and  desire  to  sleep  are  among  the  early  symp- 
toms. The  cerebral  irritation  due  to  the  pressure  on  the 
basal  nerve-trunks  completes  the  clinical  picture.  The 
frequent  occurrence  of  hemorrhage  is  a  characteristic 
symptom. 

Although  there  is  some  hope  of  involution  taking  place, 
it  is  bad  surgery  to  trust  to  it  alone,  for,  on  the  one  hand, 
it  may  not  occur,  and,  on  the  other  hand,  the  tumor  may 
produce  lasting  injuries  during  the  course  of  its  growth. 
It  is,  therefore,  advisable  to  proceed  against  the  tumors 
as  early  as  possible,  especially  as  artificial  diminution 
of  the  growth  appears  to  stimulate  spontaneous  involu- 
tion, and,  in  addition,  avoids  the  disfigurement  and  the 
danger  from  inspiration  pnenmonia  incident  to  an  ex- 
ternal operation.  The  latter  was  formerly  much  more 
commonly  performed  than  at  present,  although  it  does 
not  always  enable  the  operator  to  do  a  radical  extirpa- 
tion and  protect  the  individual  against  recurrence. 

n 


162  APPENDIX. 

Small  tumors  that  are  not  attached  to  the  walls  by 
adhesions  can  be  removed  with  the  hot  snare.  As  it  is 
often  impossible  to  introduce  the  snare  through  the  nose, 
because  the  space  of  the  nasopharynx  is  entirely  filled 
by  the  tumor,  the  free  ends  of  the  snare  may  be  intro- 
duced through  the  mouth  by  means  of  a  Bellocq  cannula 
and  drawn  out  through  the  nose.  They  are  then  drawn 
taut  around  the  tumor  by  means  of  the  carrier,  and  the 
base  of  the  tumor  is  gradually  divided.  For  the  treat- 
ment of  the  stump  and  of  tumors  that  cannot  be  removed 
with  the  snare  electrolysis  has  been  found  extremely 
useful.  Alternating  currents  of  20  to  50  milliampfires 
applied  for  a  quarter  of  an  hour — bipolar — suffice  to 
soften  the  hard  peduncle  and  cause  it  to  come  away. 
Bloody  procedures,  avulsion  of  individual  pieces  with 
the  forceps  or  with  scissors,  are  to  be  deprecated  on 
account  of  the  already  existing  anemia  in  the  patients ; 
they  are  quite  unnecessary  if  the  above-mentioned  meas- 
ures are  employed.  The  occurrence  of  postoperative  gan- 
grene in  the  necrotic  portions  can  be  avoided  by  the  free 
use  of  iodoform. 


MYCOSES. 

Thrush  is  a  frequent  disease  in  infants,  but  rarely 
occurs  in  adults.  The  mouth  and  the  anterior  portions 
of  the  pharynx  become  covered  with  the  threads  of  the 
oidium  albicans  in  small  white  islands,  which  later  coalesce 
to  form  membranes  on  a  somewhat  reddened  base  (see 
Plate  14,  Fig.  1).  The  aphthous  membrane  is  removed 
with  difficulty,  and  not  without  destroying  the  epithelium, 
as  the  threads  penetrate  the  superficial  layers  of  the  tissue. 
Secondary  lesions  may  occur  in  the  brain  and  kidneys 
through  metastases  in  the  blood-channels.  Except  for 
this  possibility  the  course  is  favorable,  unless,  as  is  chiefly 
the  case  in  adults,  the  disease  depends  on  a  grave  general 
disorder.  Thrush  never  occurs  in  the  mouth  of  healthy 
individuals.     While  in  an  infant's  mouth  the  acid  reac- 


MYCOSES.  163 

tion  in  itself  forms  a  favorable  soil  for  the  growth  of  the 
fungus,  which  may  be  derived  from  insufficiently  cooked 
food  when  the  gastric  function  is  somewhat  disturbed, 
adults  become  predisposed  only  by  a  severe  exhausting 
general  disease  or  gastric  disorder,  and  although  the 
immediate  infection  may  be  removed,  relapses  may  be 
expected  as  long  as  the  general  condition  remains  the 
same. 

Treatment  should,  therefore,  be  directed  chiefly  toward 
the  basal  cause.  The  local  treatment  consists  in  painting 
the  parts  in  infants  with  a  watery  solution  of  boric  acid ; 
in  adults,  with  an  alcoholic  solution  of  salicylic  acid. 

The  fungus,  known  as  leptothrix  buccalis,  sometimes 
invades  the  surface  of  the  tonsils.  Small  yellowish-white 
granules  are  found  at  the  orifices  of  the  crypts,  more 
rarely  on  the  neighboring  mucous  membrane,  producing 
pharyngomycosis  leptothricia  (Plate  14,  Fig.  3). 
So  far  it  has  been  found  impossible  to  distinguish  the  dis- 
ease clinically  from  chronic  cornification  of  the  epithelium, 
which  presents  a  picture  similar  in  every  respect.  The 
presence  of  the  fungus  produces  no  symptoms  beyond  the 
psychic  ones.  Empirically,  the  smoking  of  tobacco  has 
been  found  to  be  one  of  the  best  of  the  milder  remedies. 

Finally,  mention  may  be  made  of  nasal  mycosis  due 
to  the  growth  of  fungi  in  the  nose.  Aspergillus  fumigatus 
and  glaueus,  penicillium  glaucum,  and  puccinia  graminis 
have  been  found,  usually  in  the  form  of  grayish-white 
.  or  grayish-brown  friable  shreds  adherent  to  the  swollen 
mucous  membrane  of  the  nose  or  of  the  antrum.  The 
aphthous  membrane  is  readily  removed  and  emits  a  musty 
odor  like  mildew.  Purulent  secretion  has  also  been  ob- 
served. The  diagnosis  can,  of  course,  be  made  only  by 
the  aid  of  the  microscope.  A  cure  can  be  effected  by 
means  of  mechanical  cleansing  and  the  use  of  mild  anti- 
septics. 


164  NEOPLASMS. 


NEOPLASMS. 

HOMOLOGOUS   NEOPLASMS. 

Homologous  neoplasms  are  tumors  that  correspond  in 
structure  and  arrangement  with  the  basal  tissue  or  its 
component  parts.  Neoplasms  of  individual  portions  of 
tissue  present  the  true  character  of  tumors,  while  hyper- 
plasias of  several  or  of  all  the  constituents  of  the  tissue 
are  usually  inflammatory  in  nature  and  have  already  been 
discussed  in  former  sections.  The  commonest  tumor  de- 
rived from  true  connective  tissue  is  the  fibroma.  Simple 
fibromata  are  not  common  in  any  part  of  the  oropharynx. 
They  occur  in  the  form  of  a  thin,  pedunculated  tumor  on 
the  soft  palate  and  on  the  uvula  more  frequently  than 


Pig.  27.— Pedunculated  fibroma  on  the  uvula. 

elsewhere,  and  as  they  are  in  close  contact  with  the  tissues 
and  resemble  in  color  and  smoothness  the  rest  of  the 
raucous  membrane,  they  often  escape  observation  (Fig.  27). 
On  the  tongue  they  are  more  apt  to  occur  in  the  form  of 
a  broad  tumor  underneath  the  raucous  merabrane,  which 


HOMOLOGOUS  NEOPLASMS.  1^5 

may  present  superficial  proliferation  of  the  epithelium  and 
thus  mask  the  actual  neoplasm.  Broad  tumors  of  this 
kind  are  also  frequently  seen  in  the  hypopharynx  (see 
Atlas  of  Laryngology,  Plate  27,  Fig.  2). 

Granulomata  are  tumors  consisting  of  loose-meshed 
tissue,  containing  principally  round-cells.  They  occur  in 
the  neighborhood  or  at  the  site  of  frequently  repeated 
irritation,  and  accordingly  represent  true  inflammatory 
tumors.  They  are  observed  occasionally  on  the  gums  of 
carious  teeth  in  the  form  of  eptllis  (Plate  5,  Fig.  1) ; 
if  the  growth  is  derived  from  the  alveolar  periosteum,  it 
is  designated  more  correctly  a  periodontoma.  In  the 
nose  the  tumors  sometimes  occur  at  the  point  where  irri- 
tation is  most  frequent  or  around  a  traumatic  ulcer.  Here 
also  they  consist  in  the  main  of  inflammatory,  newly 
formed,  round-cell  tissue,  containing  a  few  glands ;  or 
they  present  a  somewhat  papillary  form  as  the  result  of 
epithelium  proliferation.  Owing  to  the  great  vulnera- 
bility and  exposed  position  of  these  little  tumors  and 
their  tendency  to  frequent  bleeding  they  have  received 
the  name  of  "  bleeding  polypi  of  the  septum,"  a  term  that 
should,  however,  be  discarded,  since  it  is  purely  symp- 
tomatic, and  bleeding  tumors  of  a  very  different  nature 
may  occur  in  the  same  situation.  After  a  time  these 
granulomata  may  assume  a  more  fibromatous  character 
from  the  multiplication  of  connective-tissue  fibers. 

If  the  epithelium,  either  primarily  or  secondarily,  shares 
in  the  abnormal  growth,  the  connective  tissue  is  drawn 
out  into  papillae  and  there  ensues,  if  the  epithelial  pro- 
liferation is  extreme  and  extends  into  the  depth  of  the 
tissue,  the  papillary  fibro-epithelioma ;  or,  if  the 
epithelial  covering  merely  becomes  thickened  and  main- 
tains its  relation  with  the  papillae,  the  papillary  fibroma. 
The  former  variety  may  also  be  described  as  the  hard, 
the  latter  as  the  soft,  papilloma.  The  hard  variety  is 
more  frequent  in  the  mouth,  especially  at  the  pillars  of  the 
fauces,  and  may  be  either  broad  and  sessile  or  peduncu- 
lated (Fig.  28).     It  is  rare  in  the  pharynx  and  in  the 


166 


NEOPLASMS. 


nose  (Plate  30,  Fig.  2).  The  soft  variety  preferably 
affects  the  middle  turbinate  (Plate  28,  Fig.  2),  and  is  to 
be  carefully  distinguished  from  a  lobuiated  raucous  poly- 
pus, the  base  of  the  papilloma  being  always  a  solid  plate, 
while  the  polypi  grow  each  individually  from  the  basal 
tissue. 

Strictly  speaking,  homologous  papillomata  occur  only 
in  regions  where  papillae  are  already  present.     They  are 


Fio.  28.— Papilloma  and  papilla  foliata. 

rare  in  the  nose,  because  that  structure  contains  no  pa- 
pillae, and,  accordingly,  the  epithelium  occasionally  un- 
dergoes atypical  growth  into  the  deeper  layers  (Plate  35, 
Fig.  2),  so  that  the  basal  tissue  is  destroyed.  The  clin- 
ical course  of  these  tumors  is  also  marked  by  a  strong 
tendency  to  recurrence,  indicating  a  change  to  malig- 
nancy ;  hence  the  name  "  malignant  papilloma "  is  justi- 
fied. 


HOMOLOGOUS  NEOPLASMS.  167 

The  tumors  can  usually  be  removed  without  difficulty, 
either  with  the  scissors  or  with  the  snare.  For  malignant 
tumors,  however,  the  hot  snare  should  always  be  used, 
and,  if  the  gravity  of  the  situation  appears  to  warrant  it, 
the  surgeon  should  not  hesitate  to  lay  the  interior  of  the 
nose  open. 

The  filiform  papillae  of  the  tongue  undergo  a  peculiar 
multiple  change  described  by  the  term  lingua  nigra.  The 
papilla?,  for  the  most  part,  become  greatly  elongated ; 
robust  layers  of  horny  epithelium  are  formed ;  and  the 
color  varies  from  dark-brown  to  black.  In  extreme 
cases  the  tongue  feels  as  if  it  were  covered  with  hair 
(Plate  5,  Fig.  3).  The  cause  of  this  peculiar  new  forma- 
tion is  unquestionably  specific  in  nature,  but  is  quite 
unknown.     Treatment  is  unnecessary. 

Certain  neoplasms  consisting  of  aberrant  tissue,  so-called 
lymphadenoid  polypi,  are  peculiar  to  the  oropharynx. 
They  are  found  on  the  surface  or  sides  of  the  tonsils  in 
the  form  of  pea-sized,  spheric,  slightly  elevated  tumors, 
on  a  flat  base,  and  consist  of  round-cells,  with  a  sprink- 
ling of  follicles.  Papilla  foliata  is  a  term  applied  to 
aberrant  lingual  papillae,  usually  found  adherent  to  the 
anterior  pillar  of  the  fauces  (Fig.  28). 

I/ipomata  are  met  chiefly  on  the  tongue,  on  the  floor 
of  the  mouth,  on  the  buccal  mucous  membrane,  and  as 
"  intramural "  growths  between  the  layers  of  the  soft 
palate.  Although  they  are  of  soft  consistence  and  slow 
growth,  the  diagnosis  is  sometimes  impossible  before  re- 
moval of  the  tumor  unless  the  investing  layer  is  so  thin 
that  the  yellow  color  of  the  tumor  is  seen  through  it. 

Myxomata  are  even  more  rare  than  the  last-men- 
tioned tumor,  and  have  about  the  same  distribution. 
They  occasionally  occur  in  the  nose,  usually  in  the  wake 
of  syphilitic  processes. 

Among  connective-tissue  neoplasms  must  also  be 
mentioned  cartilaginous  and  osseous  tumors.  The 
former,  when  homologous,  occur  only  in  the  form  of 
ecchondromata,  and  are  found  chiefly  on  the  septum  of 


168  NEOPLASMS. 

the  nose,  where  they  are  not  to  be  confounded  with  the 
ordinary  crests  and  spines.  They  may  be  found  on  a 
deviated  septum,  as  shown  in  Fig.  29,  but  they  are  never 


Fig.  29.— Enchondromata  of  the  septum. 

pointed  or  sharp,  like  ordinary  excrescences,  being  usu- 
ally knob-like  in  form,  and  never  contain  bone.  Homol- 
ogous osteomata  are  also  observed  in  the  form  of  exos- 


FiG.  30.— Exostosis  of  the  vomer. 


toses  (Fig.  30)  and  large  bony  tumors  within  the  nose, 
and  must  be  distinguished  from  the  ordinary  bony  hyper- 
plasia of  the  septum.     They  are  found  in  all  the  bony 


HOMOLOGOUS  NEOPLASMS.  169 

portions  of  the  nose  and  also  in  the  accessory  sinuses, 
where  they  occasionally  assume  large  size  and  produce 
marked  pressure  phenomena.  Whenever  the  tumors 
grow  rapidly  or  the  base  is  deep-seated,  they  must  be 
removed  with  the  same  thoroughness  as  a  malignant 
neoplasm. 

Neoplasms  consisting  of  muscle  tissiie  occur  in  the 
tongue  in  the  form  of  total  macroglossia,  which  is 
always  congenital,  and,  when  of  moderate  extent,  pre- 
sents  the  picture  of  lingua   dissecata   (Fig.  31).     It  is 


Fig.  31.— Lingua  dissecata. 

interesting  to  note  that  this  abnormality  is  very  apt  to 
lead  to  the  production  of  the  superficial  alteration  known 
as  geographic  tongue  (Plate  6,  Fig.  2).  Partial  fibro- 
myoma  of  the  tongue  has  been  observed  in  rare  in- 
stances. 

Vasctllar  tumors  include  the  cavernous  angioma  of 
the  pharynx,  which  sometimes  simulates  hyperplasia  of 
the  tonsils.  It  is  distinguished  from  the  latter  condi- 
tion by  the  dark-red  or  blue  color  and  the  rapidity  with 
which  it  shrinks  on  the  application  of  cocain.  It  may 
be  removed  with  the  hot  snare  or  by  galvanopuncture. 


170  NEOPLASMS. 

Aneurysm  is  a  much  rarer,  but  much  graver,  occur- 
rence. In  tlie  pharynx  aneurysm  forms  a  prominent, 
fluctuating  tumor  without  altering  the  appearance  of  the 
mucous  membrane.  In  spite  of  the  presence  of  pulsa- 
tion, which  cannot  escape  attentive  observation,  these 
tumors  have  practically  always  been  mistaken  for  cysts 
or  abscesses  and  punctured,  with  the  natural  consequence 
of  a  severe  hemorrhage.  If  the  aneurysm  is  small  and 
favorably  situated,  it  may  l)e  enucleated,  but,  as  a  rule, 
the  supplying  vessel  must  be  ligated. 

In  persons  suifering  from  chronic  catarrh  or  general 
venous  stasis  the  dilatation  of  the  pharyngeal  veins  may 
occasionally  lead  to  the  production  of  small  varices. 
These  are  said  occasionally  to  produce  hemorrhages  that 
may  be  quite  considerable,  and  require  for  their  control 
the  application  of  the  cautery. 

Neoplasms  consisting  of  lytnph-vessels  are  a  special 
feature  in  the  mouth,  occurring  chiefly  in  the  tongue. 
As  a  rule,  they  appear  to  be  of  an  embryonal  nature, 
as  is  indicated  by  the  frequency  of  their  occurrence  in 
childhood  and  their  predilection  for  the  site  of  former 
branchial  clefts.  The  exciting  cause  of  their  sub- 
sequent growth  is  usually  some  form  of  inflammatory 
irritation.  Three  principal  forms  are  distinguished : 
nodules,  warts,  and  the  difihse  or  cystic  lymph- 
angioma. 

The  nodular  variety  occurs  most  frequently  at  the 
base  of  the  tongue,  in  the  form  of  a  broad,  wart-like 
aggregation  of  hemispheric  vesicles  so  minute  that  their 
true  nature  can  sometimes  be  recognized  only  with  a 
lens.  A  few  scattered  nodules  may  be  found  by  the 
side  of  the  principal  aggregation.  The  diagnosis  is  com- 
plicated by  the  occurrence  of  frequent  traumatic  hemor- 
rhages and  the  variable  nature  of  the  inflammation,  which 
may  be  superficial  or  extend  into  the  deeper  layers  of 
the  tongue  and  into  adjoining  structures. 

The  diffuse  variety  presents  the  picture  of  a  general 
enlargement  of  the  lips  and  tongue,  with  a  few  visible 


HOMOLOGOUS  NEOPLASMS.  VJV 

vesicles.     The  secondary  changes  in  this  variety  are  very 
marked  and  greatly  confuse  the  diagnosis. 

The  rarest  form  of  all — a  real  clinical  curiosity  and 
one  that  can  be  identified  only  by  means  of  the  micro- 
scope— is  the  lymphatic  cyst,  a  smooth  hollow  tumor 
which  so  far  has  been  chiefly  observed  in  the  tongue. 

These  lymphatic  tumors  are  best  treated  by  means  of 
wedge-shaped  excision,  because  the  tumors  usually  infil- 
trate the  healthy  tissue.  The  indications  for  interference 
are  rapid  growth  and  secondary  changes.  Small  tumors 
of  this  kind  may  exist  indefinitely  without  producing 
symptoms. 

Glandular  tumors  may  occur  anywhere,  as  hyper- 
trophies both  of  the  glandular  layer  of  the  turbinates 
and  of  the  raucous  and  salivary  glands  of  the  mouth  and 
pharynx.  They  take  the  form  either  of  solid  (diffuse 
or  circumscribed)  adenomata  or  of  cysts.  The  diffuse 
variety  is  met  most  frequently  on  the  upper  lip,  where 
it  produces  the  deformity  known  as  "double  lip,"  and 
consisting  of  an  additional  fold  of  mucous  membrane 
behind  the  normal  vermilion  ;  it  is  best  removed  by 
means  of  a  wedge-shaped  incision.  Circumscribed  ad- 
enoma occurs  as  a  solid,  soft  tumor,  sometimes  in  the  nose 
in  the  shape  of  a  polypus  (Plate  35,  Fig.  1),  sometimes 
in  the  oropharynx  as  a  broad,  flat  hyperplasia  of  indi- 
vidual salivarv  glands  or  as  multiple  small  tumors  of  the 
mucous  glands. 

Cystic  degeneration  occurs  chiefly  as  a  concomitant  of 
inflammatory  hyperplasia  of  the  turbinates  (Fig.  36); 
more  rarely  it  occurs  in  the  form  of  isolated  multiple 
cvst-formation  in  the  same  region.  In  the  pharynx  it 
is  more  common  and  represents  the  degeneration  of  indi- 
vidual mucous  glands.  Next  in  frequency  of  localization 
is  the  base  of  the  tongue;  and  after  that  the  various 
portions  of  the  oral  mucous  membrane;  in  the  latter 
situation  the  cvsts  rarely  exceed  the  size  of  a  i)ea. 

Cystic  degeneration  of  the  salivary  glands  on  the 
floor  of  the  mouth  leads  to  the  formation  of  a  typical 


172 


NEOPLASMS. 


tumor  known  as  a  ranula.  When  the  tumor  occupies 
a  median  position  it  appears  to  be  double,  owing  to  con- 
striction by  the  frenulum  linguae  (Fig.  32).  The  cysts 
are,  as  a  rule,  readily  recognized  when  they  lie  near  the 
surface.  If  they  are  more  deeply  situated,  an  explora- 
tory puncture  may  be  necessary  ;  before  this  is  done,  how- 
ever, the  differential  diagnosis  from  a  vascular  tumor 
must  be  clearly  established.  The  treatment  consists  in 
total  removal  by  means  of  constriction ;  or,  if  the  tumor 
is  situated  on  a  broad  base,  in  extirpation  of  the  cyst-wall. 


Pig.  32.— Ranula. 

In  this  connection  it  may  be  well  to  refer  once  more 
to  the  cysts  that  are  sometimes  produced  by  adhesions 
between  adjacent  portions  of  the  mucous  membrane  after 
inflammatory  processes.  They  occur  chiefly  in  the  re- 
gion of  the  lymphatic  ring,  and  have  already  been  re- 
ferred to  on  p.  144.  These  cysts  may,  however,  also  be 
formed  in  other  portions  of  the  pharynx,  particularly  at 
the  site  of  the  branchial  clefts.  Hence  they  cannot 
always  be  distinguished,  on  the  one  hand,  from  dermoid 
cysts ;  and,  on  the  other  hand,  owing  to  the  fact  that  they 
are  lined  with  epithelium,  from  cystic  glands. 


HETEROLOGOUS  NEOPLASMS.  173 

HETEROLOGOUS  NEOPLASMS. 

These  tumors  diflPer  from  normal  tissue  either  by,  first, 
an  atypical  arrangement  of  already  existing  structural 
elements,  or,  second,  by  the  presence  within  their  sub- 
stance of  foreign  (atypical  or  abnormal)  elements. 

Most  of  the  tumors  of  the  first  class  also  show  a  ten- 
dency to  atypical,  unlimited  growth,  and  are,  therefore, 
maligfnatit.  Even  when  they  do  not  possess  this  clin- 
ical peculiarity  at  the  outset  they  usually  tend  to  develop 
it  later  on  in  their  course.  This  is  especially  true  of 
endotheliomata.  Such  tumors  are  composed  of  hyper- 
plastic endothelium  and  perithelium  of  lymph-  and 
blood-vessels,  and  accordingly  present  a  reticulated 
stroma  containing  large  and  small  nests  of  epithelioid 
cells  the  original  nature  of  which  is  difficult  to  recog- 
nize, partly  owing  to  the  presence  of  fatty  and  mucoid 
degeneration  and  partly  owing  to  their  conversion  into 
dense  connective  tissue  and  cartilage.  The  nature  of 
the  tumor  is,  accordingly,  masked  by  a  great  variety  of 
histologic  pictures.  Not  infrequently  the  growth  be- 
comes excessive  and  leads  to  the  formation  of  alveolar 
(endothelial)  sarcoma  or  angiosarcoma,  in  which  all  the 
elements  of  the  blood-vessels  are  represented  (Plate  42). 
This  degenerative  process  may  be  observed  in  any  por- 
tion of  the  nasopharynx,  whereas  the  typical  endothelioma 
occurs  almost  exclusively  in  the  substance  of  the  soft 
palate,  and  if  an  "  intramural "  tumor  is  discovered  be- 
tween the  two  laminae  of  the  mucous  membrane,  the  diag- 
nosis of  endothelioma  in  most  cases  is  justifiable. 

There  is  no  doubt  that  these  peculiar  neoplasms  are 
derived  from  remains  of  embryonal  tissue  in  the  same 
wav  as  the  juvenile  sarcomata  of  the  nasopharynx  and  the 
equally  intramural  myosarcomata,  that  have  been  de- 
scribed on  p.  160. 

Ordinary  sarcoma,  consisting  chiefly  of  round-cells, 
more  rarely  of  spindle-cells,  occurs,  in  the  pharynx, 
chieflv  on   the  tonsils;   in  the   nose  its   seat  of  predi- 


174  NEOPLASMS. 

lection  is  the  anterior  portion  of  the  septum,  so  fre- 
quently referred  to  as  the  commonest  seat  of  irritation, 
while  on  the  turbinates  and  in  the  nasopharynx  it  is 
of  distinctly  less  frequent  occurrence  (see  Plate  23,  Fig. 
1).  In  the  pharynx  it  appears  as  knob-like  or  nodular 
outgrowths,  more  rarely  as  a  diffuse  infiltration,  while  in 
the  nose,  at  least  during  the  early  stages,  it  appears  as 
a  small  bosselated  tumor  on  a  broad  base  that  evinces  a 
great  tendency  to  hemorrhage.  Glandular  enlargement 
occurs  early. 

A  neoplasm  that  is  attached  to  the  mesopharynx  is  the 
lymphosarcoma,  which  is  more  characteristic  clinic- 
ally than  histologically.  It  consists  of  small  round-cells 
with  large  nuclei,  disposed  in  an  alveolar  arrangement, 
while  the  tumor  itself,  which  is  situated  underneath  the 
mucous  membrane, — usually  of  the  tonsils,  the  palatal 
arches,  or  the  uvula, — has  a  slightly  wavy  surface,  is 
rather  pale  in  color  (Plate  11,  Fig.  2),  and  characterized 
by  slow  growth.  A  dense  nodular  infiltration,  matting 
together  the  cervical  and  retromaxillary  and  submaxil- 
lary glands,  develops  early  and  may  attain  gigantic  pro- 
portions. Both  the  clinical  and  the  pathologic  diagnosis 
in  a  given  case  are  complicated  by  the  fact  that  these 
tumors  sometimes  become  converted  into  multiple  leu- 
kemic tumors,  the  nature  of  which  is  confirmed  by  the 
typical  findings  in  the  blood  and  by  the  fact  that  the 
glandular  infiltration  may  entirely  overshadow  the  phar- 
yngeal tumor,  exactly  as  in  the  case  of  pseudoleukemia. 
These  tumors  also  possess  the  peculiarity  that  they  react 
to  arsenic  with  such  promptness  as  to  give  rise  to  the 
most  optimistic  hopes  of  recovery,  hopes  that  in  most 
cases  are  doomed  to  disappointment ;  for,  although  they 
apparently  shrink,  they  may  suddenly  begin  to  take  on 
new  development.  Although,  therefore,  in  any  individ- 
ual case  the  question  whether  the  tumors  are  merely  local 
or  represent  a  symptom  of  a  hidden  general  disease  can- 
not be  decided,  early  and  radical  extirpation,  as  in  the 
case  of  ordinary  sarcoma,  is,  nevertheless,  to  be  advised. 


HETEROLOGOUS  NEOPLASMS.  175 

After  the  operation  the  general  condition  of  the  patient 
should  be  supported  by  giving  arsenic  in  liberal  doses, 
frequently  varying  the  form  of  the  remedy.  Operations 
on  large  sarcomata  of  any  kind  are  not  very  hopeful, 
because  the  tumors  have  usually  become  intimately  united 
with  vital  organs  in  the  neck  or  at  the  base  of  the  skull. 

Carcinoma  may  occur  in  any  portion  of  the  upper 
mucous  membranes.  Histologically,  squamous,  cylindric, 
and  glandular  carcinomata  are  distinguished.  The  so- 
called  villous  cancer  of  the  nose  is  probably  identical 
with  the  malignant  papilloma.  The  favorite  seat  of 
cancer  is — in  the  mouth,  the  lips,  tongue,  and  buccal 
mucous  membrane  opposite  the  interdental  cleft ;  in  the 
pharynx,  the  tonsils ;  in  the  nose,  probably  the  anterior 
portion  of  the  septum,  the  inferior  turbinates,  and  the 
antrum  of  Highraore.  It  is  only  in  the  latter  cavities 
that  true  tumors  are  produced ;  in  the  mouth  and  plmr- 
ynx  carcinoma  manifests  itself  chiefly  in  the  form  of  a 
rigid,  irregular  infiltration  that  early  undergoes  ulceration, 
or  merely  in  the  so-called  "  carcinomatous  ulcer,"  with  a 
remarkably  rigid  and  thickened  base  (Plate  12,  Fig.  2). 

On  the  lip  the  carcinomatous  infiltration  may  persist 
for  some  time  without  spreading  or  undergoing  ulceration 
(Plate  1,  Fig.  2).  It  appears  usually  in  the  form  of  a 
wart  or  a  flat  swelling  with  central  depression  which  ulti- 
mately undergoes  more  rapid  enlargement  and  extends  to 
neighboring  tissues. 

In  the  tongue  the  seats  of  predilection  are  the  margin 
and  the  anterior  half,  the  base  being  rarely  attacked.  It 
is  caused  in  almost  every  instance  by  a  carcinomatous 
degeneration  of  patches  of  leukoplakia  and  decubital 
ulcers  due  to  the  irritation  of  teeth,  just  as  lip-cancer 
very  frequently  owes  its  origin  to  traumatic  injuries,  such 
as  the  irritation  of  a  pipe-stem.  On  the  surface  of  the 
tongue  the  cancer  usually  takes  the  form  of  a  broad  infil- 
tration, while  along  the  margins  it  is  represented  by  a 
flat,  carcinomatous  ulcer  with  raised  edges.  Glandular 
enlargement  occurs  late,  just  as  in  the  case  of  lip-cancer. 


176  NEOPLASMS. 

During  the  subsequent  course  the  carcinoma  extends  to 
all  the  neighboring  parts,  so  that  the  original  seat  can 
scarcely  be  recognized.    ' 

The  same  is  true  of  carcinoma  of  the  buccal  and  inter- 
maxillary mucous  membrane.  It  usually  follows  decubital 
ulcers  from  irritation  of  the  teeth,  and,  owing  to  its  posi- 
tion near  movable  parts,  it  early  leads  to  impaired  mo- 
bility. 

Cancer  is  also  observed  on  the  hard  palate  in  the  form 
of  irregular,  spheric,  deep  infiltrations  (glandular  cancer), 
which  tend  to  break  through  into  the  nose  and  antrum. 

Within  the  nose  and  in  the  nasopharyngeal  space  carci- 
noma is  quite  rare  ;  when  it  occurs  it  forms  an  irregular, 
speckled  tumor,  characterized  by  a  great  tendency  to 
bleed,  but  its  true  nature  is  rarely  recognized  until  the 
disease  has  reached  an  advanced  stage. 

In  general  the  diagnosis  of  these  tumors  is  not  by  any 
means  easy.  On  the  lip,  it  is  true,  the  appearance  is 
quite  typical ;  but  in  the  other  portions  of  the  mucous 
membrane  epithelioma  must  be  distinguished  from  be- 
nign tumors  and  sarcoma,  and  especially  from  infectious, 
chiefly  syphilitic,  processes.  It  is  to  be  remembered  also 
that  cancer  and  syphilis  are  not  rarely  associated  in  the 
mouth,  and  that  an  ulcerated  gumma  may  become  con- 
verted into  a  cancer.  Syphilitic  lesions,  speaking  broadly, 
prefer  the  central,  and  carcinomata  the  lateral,  portions 
of  the  structures,  especially  of  the  palate,  but  the  rule  is 
subject  to  many  exceptions.  Multiple  cancers  are  ex- 
tremely rare,  while  gummata  not  infrequently  develop  in 
several  places  at  once  or  follow  one  another  in  rapid  suc- 
cession. The  punched-out  appearance  of  the  tertiary 
ulcer  serves  to  distinguish  it  in  most  cases  from  the  more 
superficial,  discolored  carcinomatous  ulcer  with  its  ele- 
vated edges  and  the  dense  infiltration  around  its  base. 
Other  points  in  the  differential  diagnosis  are  the  predilec- 
tion of  cancer  for  the  third  and  fourth  decades,  and  the 
presence  of  cachexia,  which  often  develops  quite  early. 
As  a  last  resort  a  therapeutic  test  must  be  applied,  begin- 


CONGENITAL  NEOPLASMS.  177 

ning  at  once  witli  relatively  large  doses  of  potassium 
iodid — 10  to  1 5  grams  (2.5  to  4  drams)  in  a  dose.  In 
many  cases  microscopic  examination  of  an  excised  frag- 
ment may  clear  up  tlie  diagnosis,  it  being  borne  in  mind, 
however,  that  syphilitic  ulcers  are  frequently  surrounded 
by  proliferations  of  epithelium  containing  cancer-nests. 

A  serious  error  may  arise  in  the  case  of  primary  lesions 
situated  on  the  tonsils.  The  subchronic  course,  the  density 
of  the  infiltration,  and  the  cup-shaped  depression  are  par- 
ticularly apt  to  simulate  the  appearances  of  cancer. 

Even  tuberculosis,  chronic  phlegmonous  processes  with 
insufficient  evacuation,  and  actinomycosis  must  be  borne 
in  mind  to  guard  against  possible  error. 

In  the  nose  the  error  of  mistaking  carcinoma  or  sarcoma 
for  a  suppurative  process  in  one  of  the  accessory  sinuses 
cannot  always  be  avoided ;  for  if  the  tumor  is  deeply 
situated,  it  reveals  itself  at  first  only  by  the  secondary 
suppuration  or  by  the  production  of  inflammatory  polypoid 
or  granular  proliferations,  which  are  particularly  mislead- 
ing. Cachexia,  early  motor  and  sensory  disturbances, 
and  metastatic  enlargement  of  the  glands  must  be  care- 
fully looked  for. 

CONGENITAL  NEOPLASMS. 

The  last,  the  congenital  neoplasms,  depending  on  em- 
bryonal abnormalities,  form  another  class  of  heterologous 
tumors.  True  epignathal  growths  or  remains  of  a  second 
germ,  which  properly  belong  to  the  subject  of  teratology, 
may  be  left  out  of  consideration.  Among  the  tumors 
representing  aberrant  portions  and  excrescences  of  the 
germinal  layer  of  the  same  individual  are  the  so-called 
hairy  pharyngeal  polypi.  These  tumors  are  usually 
of  moderate  size ;  their  stroma  consists  either  of  fatty  or 
of  fibrous  tissue,  in  which  lie  imbedded  portions  of  car- 
tilaginous, nervous,  or  muscular  tissue  or  even  teeth ; 
while  the  presence  of  sebaceous  and  sudorific  glands  in 
the  superficial  layer  and  in  the  hairy  covering  indicates 

12 


178 


NEOPLASMS. 


their  ectodermal  origin.  Sometimes  they  pre>ont  a  cystic 
character — in  other  words,  they  are  dermoid  cysts. 
The  first  variety  is  usually  found  on  the  palate,  the  second 
occurs  as  a  unilateral  tumor,  either  submental — beneath 
the  base  of  the  tongue — or  sublingual — beneath  the  tip 
of  the  tongue  (Fig.  33).  \\  ithin  the  nose  and  in  the 
antrum  of  Highraore  supernumerary  teeth  are  sometimes 
observed,  standing  with  the  crown  directed  upward,  and 
representing  rests  of  inverted   odontoblasts.     True 


Fig.  33.— Sublingual  dermoid. 

cyst-formation  occurs  only  in  the  antrum,  and  requires  to 
be  accurately  distinguished  from  dental  cysts  (periodontal 
cysts). 

A  peculiar  form  of  tumor  derived  from  aberrant  germi- 
nal tissue  is  the  so-called  accessory  struma  (or  thyroid 
gland),  which  is  completely  separated  from  the  outer  thy- 
roid gland.  Its  nature  can  be  recognized  only  by  means 
of  the  microscope.  The  favorite  seat  is  the  base  of  the 
tongue,  where  the  tumor  grows  from  the  remains  of  the 


CONGENITAL  NEOPLASMS.  179 

tlivroglossiis  duct.  The  tumor  must  be  distinguished  from 
retrovisceral  struma  or  ahuormal  lobes  of  tlie  thyroid 
gland.  These  may  extend  far  behind  the  structures  of 
the  mouth  and  pharynx,  but  always  maintain  some  com- 
munication with  the  principal  gland. 

Clinically,  it  is  necessary  to  distinguish  benign  and 
malignant  tumors.  Malignant  tumors  are  again  sub- 
divided into  those  which,  although  not  presenting  atypical 
growth,  may,  from  their  position  within  a  closed  cavity, 
give  rise  to  dilatation  of  that  cavity,  and  thus  lead  to 
grave  disturbance  of  the  general  health  or  even  fatal 
results ;  and  malignant  tumors,  in  the  strict  sense  of  the 
term,  which,  by  their  atypical  growth,  destroy  the  normal 
tissue  and  bring  on  their  own  destruction  and  disinte- 
gration by  interfering  with  the  blood-supply. 

The  second  variety  includes  all  forms  of  sarcoma  and 
carcinoma ;  the  first  embraces  juvenile  sarcomata,  endo- 
theliomata,  and  their  derivatives,  including  dermoids. 
All  other  tumors  may  be  called  benign,  except  in  so  far 
as  the  presence  of  any  growth  at  the  upper  boundary  of  the 
digestive  tract  and  lower  boundary  of  the  air-passages  may 
threaten  life,  even  though  it  may  be  of  very  slow  growth 
and  attain  a  very  small  size.  Tumors  within  the  mouth 
and  pharynx  are  constantly  exposed  to  injury,  and  pre- 
sent the  appearance  of  ulceration,  which  may  be  more 
than  superficial,  thus  making  them  more  liable  to  be  con- 
founded with  spontaneously  ulcerating  malignant  tumors 
or  with  specific  processes. 

Such  conditions  must  be  regarded  as  secondary,  and 
although  they  may  give  a  uniform  clinical  character  to 
tumors  of  widely  different  kinds,  they  should  not  be 
allowed  to  affect  therapeutic  measures. 

In  the  nose  and  nasopharynx  the  presence  of  a  tumor 
first  declares  itself  by  interference  with  the  breathing. 
Hemorrhage  is  also  a  common  symptom,  partly  on  ac- 
count of  the  passive  congestion,  and  partly  on  account  of 
unavoidable  small  traumatisms.  As  the  growth  be- 
comes larger  it  may  be  seen  at  the  vestibule  or  in  the 


180  NEOPLASMS. 

pharynx.  When  the  tumor  is  deep-seated  or  tends  to 
grow  inward,  the  unpleasant  symptoms  of  pressure  and 
tension  are  produced.  The  confusion  arising  from  the 
accompanying  suppurations  and  secondary  proliferative 
processes  in  the  raucous  membrane  has  already  been  re- 
ferred to.  Twisting  or  constriction  of  the  pedicle  of  a 
benign  tumor,  and  spontaneous  necrosis  of  a  malignant 
tumor,  may  give  rise  to  gangrene  and  tissue  decay  with 
hemorrhage ;  but  as  these  phenomena  appear  only  in  the 
advanced  stages,  they  cannot  be  said  to  have  any  diag- 
nostic value.  It  is  well  to  remember  that  necrosis  of 
bone  may  result  from  the  pressure  of  large  tumors  or  the 
invasion  of  the  bone  by  malignant  growths,  because  the 
condition  is  apt  to  be  mistaken  for  the  product  of  a  specific 
process  or  of  tlie  presence  of  a  foreign  body. 

In  the  mouth  even  a  small  tumor  may  become  very 
troublesome  by  the  salivation,  abnormal  sensation,  and 
the  sense  as  of  a  foreign  body  to  which  it  gives  rise,  as 
also  by  producing  a  hypochondriac  fear  of  cancer  in  tlie 
patient's  mind.  If  the  tumor  is  of  any  size,  mastication 
becomes  difficult ;  the  patient,  to  his  great  discomfort,  is 
constantly  biting  his  tongue,  and  these  repeated  trauma- 
tisms obscure  the  clinical  picture,  as  very  few  tumors  will 
withstand  the  constant  injury  without  breaking  down. 
Pain  is,  of  course,  a  frequent  symptom.  When  the  tumor 
is  situated  in  the  posterior  portion  of  the  mouth,  the 
movements  of  the  jaws  are  abolished,  either  by  reflex 
means  or  from  mechanical  interference,  particularly  when 
the  intermaxillary  fold  is  involved. 

Pharyngeal  tumors,  besides  giving  rise  to  symp- 
toms similar  to  those  that  have  just  been  described,  inter- 
fere very  much  with  the  mechanism  of  deglutition  ;  the  food 
regurgitates  into  the  nose  or  passes  into  the  larynx  ;  the 
patient  has  great  difficulty  in  eating ;  there  is  pressure  on 
the  larynx  or  on  some  of  its  muscles,  such  as  the  posti- 
cus; and,  finally,  the  patient  complains  of  pain,  which 
usually  radiates  toward  the  ear. 

Treatment. — Destruction   or  extirpation  is,  of  course, 


MUCOUS  MEMBRANES  IN  DISEASE.  181 

the  only  method  to  be  considered.  The  only  question 
that  remains  to  be  decided  is  whether  the  extirpation 
shall  be  total  or  partial,  ^yhenever  it  is  possible,  access 
should  be  gained  through  the  natural  passages ;  but  in  the 
case  of  malignant  tumors,  a  preliminary  operation  will 
frequently,  and  in  fact  usually,  be  necessary.  Even  in 
the  nose,  and  when  the  tumors  are  small  and  situated  at 
the  entrance,  the  surgeon  should  not  shrink  from  free  ex- 
posure of  the  field  of  operation  if  he  finds  any  difficulty 
whatever  in  obtaining  a  clear  view,  or  if  the  tumor  has 
returned  after  an  endonasal  operation. 

For  the  removal  of  tumors  situated  at  the  anterior  por- 
tion of  the  septum  the  lateral  operation,  as  described  on 
p.  51,  is  suitable.  Tumors  in  the  lateral  portion  of  the 
ethmoid  region  may  be  reached  by  temporarily  displacing 
the  eyeball,  as  described  on  p.  107 ;  tumors  in  the  supe- 
rior anterior  portions  of  the  nose  will  require  Langen- 
beck's  temporary  resection  of  the  superior  maxilla ;  and, 
if  still  more  room  is  required,  the  entire  nose  must  be 
opened  up. 

The  removal  of  tumors  from  the  deeper  portions  of  the 
pharynx  practically  always  requires  some  preliminary 
operation,  and  often  a  very  extensive  one,  which  need  not 
be  explained  in  this  place. 

APPEARANCES  OBSERVED  IN  THE  UPPER 
MUCOUS  MEMBRANES  EST  GENERAL  DIS- 
EASES. 

Certain  symptomatic  inflammations  have  been  discussed 
in  other  portions  of  this  work  (see  pp.  70  and  119).  In 
addition,  the  nose  and  oropharynx  take  part  in  many 
other  general  diseases.  Anemia  and  chlorosis  are 
characterized  by  great  pallor  of  the  mucous  membrane, 
by  abnormal  dryness  in  the  throat  and  nose,  and,  as  a 
consequence,  a  desire  to  cough,  and  the  feeling  as  of  a 
foreign  body.  Chlorotic  girls  are  much  subject  to  dis- 
eases of  the  teeth  and  of  the  gums. 


182  MUCOUS  MEMBRANES  IN  DISEASE. 

A  similar  feeling  of  dryness,  which  may  or  may  not  be 
accompanied  by  atrophy  of  the  mucous  membrane,  is  also 
observed  in  diabetes. 

Passive  hyperemia  is  a  constant  concomitant  of  most 
chronic  digestive  disturbances,  and  also  forms  part 
of  the  circulatory  symptoms  observed  in  cirrhosis  of 
the  liver  and  in  ciironic  disease  of  the  heart  and  kidneys. 
In  the  milder  grades  the  mouth  and  throat  are  of  a  dusky 
red,  and  the  erectile  tissue  in  the  nose  is  hyperemic ;  later 
the  veins  at  the  base  of  the  tongue  and  in  the  mesopharynx 
become  permanently  dilated  and  tortuous,  and  finally 
hemorrliages  may  occur  from  diapedesis.  Hemorrhage  of 
this  kind  is  characteristic  of  scurvy  (Plate  1,  Fig.  1  ;  Plate 
17,  Fig.  1),  morbus  maculosus  Werlhofii,  Barlow's  disease, 
leukemia,  and  pseudoleukemia.  The  last  disease  is  often 
accompanied  by  great  hyperplasia  of  the  lymphatic  ring, 
in  addition  to  which,  in  leukemia,  yellowish-white,  mar- 
rowy infiltrations  may  be  present  in  various  portions  of 
the  pharynx. 

A  rare  condition  known  as  Moller'S  glossitis  some- 
times develops  under  the  influence  of  chronic  intes- 
tinal disorders.  It  consists  of  a  superficial  exudative 
inflammation  of  the  tongue,  the  appearance  of  which  re- 
sembles that  of  the  geographic  tongue,  except  that  the 
eruption  is  constant  and  painful. 

Vasomotor  disturbances  in  the  nasal  mucous  mem- 
brane not  infrequently  depend  upon  the  sexual  life  of 
the  individual,  especially  in  the  female  sex. 

Hyperemia  of  the  erectile  tissue  in  the  form  of  obstruc- 
tion or  severe  nasal  catarrh  tends  to  recur  at  each  men- 
strual period  ;  and  similar  catarrhal  symptoms,  or  even 
asthmatic  conditions,  that  may  or  may  not  be  noticed, 
almost  regularly  attend  the  climacteric.  Asthma  has 
also  been  observed  in  men  after  excessive  sexual  excite- 
ment. Both  during  menstruation  and  during  the  climac- 
teric vicarious  hemorrhage  has  been  known  to  occur  from 
the  nose.  As  these  hemorrhages  are  often  quite  alarming 
and  not  in  the  least  affected  by  the  usual  styptics,  it  is 


DISEASES  OF  THE  NERVES  AND  MUSCLES.    183 

exceedingly  important  to  recognize  their  true  nature,  since 
they  are  controlled  by  the  extract  of  hydrastis  canadensis, 
in  exactly  the  same  way  as  in  metrorrhagia.  Almost 
every  inflammatory  disease  aifecting  the  nasal  region  is 
more  or  less  subject  to  the  influence  of  sexual  life  in 
women. 

Tabes  and  syringomyelia  are  occasionally  accom- 
panied by  certain  trophic  disturbances,  the  former  by  loss 
of  teeth  and  ulcers  resembling  "  rnal  pcrforanf,"  the  latter 
by  tniumatic  ulcers  and  tissue-loss  resulting  from  hypes- 
thesia. 

Skin-diseases  that  involve  the  mucous  membranes 
can  always  be  diagnosed  by  the  distribution  of  the  cuta- 
neous lesions.  Thus  in  almost  half  the  cases  of  lichen 
planus  circular  and  serpentine  groups  of  hard  white 
nodules,  the  size  of  a  lentil,  are  found  in  the  mouth  and 
on  the  palate.  Pemphigus,  both  the  vegetating  and  the 
bullous  variety,  is  very  rarely  localized  in  the  mouth,  and 
its  appearance  here  is  a  very  bad  prognostic  sign  for  the 
general  course  of  the  disease.  The  eruptions  are,  of 
course,  much  less  distinct  on  the  mucous  membrane  than 
on  the  cutaneous  surface,  because  vesicles  never  persist 
for  any  length  of  time  (see  p.  74).  The  same  is  true  of 
the  eruption  of  exudative  erj'thema  in  the  mouth.  A  few 
rare  conditions  in  which  skin  diseases  of  various  kinds 
extend  directly  from  the  vermilion  of  the  lips  to  the 
mucous  membrane  need  no  special  explanation. 

DISEASES  OF  THE  NERVES  AND  MUSCLES. 
MOTOR  DISTURBANCES. 
Hjrpokinetic  disturbances  of  muscular  origin  are 
sometimes  met  in  the  external  nose.  The  function  of  the 
levator  alse  nasi,  owing  either  to  congenital  weakness  or 
to  atrophy  from  disuse,  is  sometimes  so  much  impaired  in 
mouth-breathers  that  the  inspiratory  current  of  air  does 
not  meet  with  the  necessary  resistance  and  compresses  the 
nose,  thus  interfering  materially  with  respiration.     The 


184     DISEASES  OF  THE  NERVES  AND  MUSCLES. 

condition  can  be  corrected  by  the  wearing  of  supporting 
apparatus,  among  which  the  most  suitable  is  that  devised 
by  Schmithuisen. 

Paralyses  in  the  mouth  and  pharynx  are  almost  always 
due  to  disturbances  of  innervation.  Paralyses  of  cerebral 
origin  are  typically  exemplified  in  bulbar  paralysis,  a  dis- 
ease in  which  the  lips,  the  tongue,  the  soft  palate,  and 
finally  the  deeper  pharyngeal  muscles  are  attacked. 
Articulation  is  first  interfered  with;  later  the  patient 
becomes  unable  to  swallow,  the  food  is  not  properly  con- 
veyed into  the  esophagus,  but  remains  in  part  on  the  base 
of  the  tongue.  Some  of  these  bulbar  symptoms,  or  in  rare 
cases  all  of  them,  may  be  produced  by  disease  in  other 
nuclei  situated  in  the  medulla  oblongata,  just  as  they  are 
produced  in  all  system  diseases,  tabes,  sclerosis,  and  the 
like,  and  in  a  more  accidental  manner  by  the  presence  of 
tumors  and  syphilitic  processes.  The  nuclei  concerned 
are  those  of  the  spinal  accessory,  hypoglossus,  and  glosso- 
pharyngeus  nerves.  The  question  whether  a  high  'injury 
of  the  facial  nerve  affects  the  muscles  of  the  pharynx  still 
remains  undecided.  The  inconstancy  with  which  the 
nerve  appears  to  be  concerned  in  the  action  of  the  soft 
palate  probably  depends  on  certain  individual  peculiarities 
in  the  distribution  of  its  branches. 

Peripheral  palsies  are  sometimes  due  to  the  presence  of 
tumors  and  suppurations  at  the  base  of  the  skull.  They 
are  rarely  isolated,  being,  as  a  rule,  associated  with  paral- 
ysis of  other  cranial  nerves.  Neuritis  of  isolated  branches, 
on  the  other  hand,  is  observed  somewhat  more  frequently ; 
it  rests  on  an  infectious  basis.  The  most  important  ex- 
ample is  found  in  the  diphtheric  palsies  of  the  soft  palate 
and  uvula,  although  these  may  also  be  due  to  some  other 
infectious  inflammatory  disease  of  the  pharynx,  or  even 
to  pressure,  such  as  that  of  a  hyperplastic  tonsil.  Severe 
postdiphtheric  palsies  are  readily  recognized  by  the  re- 
gurgitation of  food  into  the  nose  from  inability  to  shut 
off  the  upper  air-passages,  and  by  the  presence  of  rhino- 
lalia aperta,  which  renders  the  speech  quite  unintelligible 


MOTOR  DISTURBANCES.  185 

and  which  may  persist  in  a  mitigated  form  long  after  con- 
valescence has  been  established. 

Paralysis  of  the  palate,  whether  complete  or  partial, 
is  usually  bilateral.  Unilateral  palsy  occurs  practically 
only  in  connection  with  paralysis  of  the  spinal  accessory, 
which  is  recognized  by  paralysis  of  the  recurrent  nerve. 
The  condition  is  most  commonly  due  to  some  process  at 
the  base  of  the  skull. 

Total  paralysis  of  the  muscles  of  deglutition  may  neces- 
sitate artificial  feeding,  if  only  to  prevent  the  occurrence 
of  inspiration  pneumonia.  If  there  is  any  prospect  of 
recovery  or  improvement,  peripheral  palsies  should  be 
treated  by  local  massage  and  faradization.  The  good 
effects  that  probably  follow  the  administration  of  strychnin 
have  been  discussed  on  p.  62. 

Hyperkinetic  Disturbances.— In  nervous  persons 
intention  spasms  of  the  lips  and  extending  to  other  mus- 
cles of  articulation  and  phonation  are  sometimes  provoked 
by  the  attempt  to  speak.  The  condition  represents  a 
variety  of  stammering.  An  occupation-neurosis  in  the 
form  of  spasm  of  the  tongue  has  been  observed  in  clarinet 
performers.  Perverse  innervation  of  the  soft  palate  during 
the  acts  of  speaking  and  swallowing,  identical  with  per- 
verse innervation  of  the  larynx,  occurs  in  paralytic  and 
hysteric  individuals ;  the  nasopharynx,  instead  of  being 
closed,  is  opened,  with  the  usual  consequences. 

Tonic  and  clonic  convulsions  of  the  orbicularis  oris,  the 
muscles  of  the  tongue,  and  the  muscles  of  deglutition — 
trismus — may  be  produced  reflexly  by  painful  processes 
in  the  mouth,  such  as  carious  teeth.  The  condition  de- 
])ends  on  a  general  neurotic  diathesis  or  on  central  or  peri- 
pheral irritation  of  the  nerves  feoncerned  in  the  reflex  act. 

Tonic  convulsion  of  the  pharynx  is  a  familiar  symptom 
of  rabies,  and  occurs  also  in  the  early  stages  of  central 
palsies.  The  spasm  destroys  the  power  of  speech  and 
deglutition,  but  the  visible  structures,  particularly  the 
soft  palate,  are  seen  to  be  tensely  stretched  instead  of 
flexed,  as  is  the  case  in  paralysis. 


186     DISEASES  OF  THE  NERVES  AND  MUSCLES. 

Such  spasms  of  hysteric  nature  may,  by  arresting  a 
bohis  of  food  or  closing  on  an  esophageal  sound  inserted 
for  purposes  of  examination,  simulate  stenosis  in  the  lower 
portion  of  the  pharynx  or  upper  portion  of  the  esophagus, 
or  even  a  diverticulum  of  the  esophagus.  The  diagnosis, 
therefore,  requires  careful  consideration  of  the  general 
condition,  repeated  examinations,  and  a  prolonged  period 
of  observation.  When  the  spasms  are  due  to  rabies  or  a 
central  lesion,  they  are,  of  course,  hopeless ;  the  hysteric 
spasms,  however,  can  be  successfully  treated  by  psychic 
means. 

A  condition  that  is  so  rare  as  to  acquire  the  character 
of  a  curiosity  consists  in  clonic  rhythmic  contractions  of 
the  soft  palate  and  uvula.  It  occurs  occasionally  in  asso- 
ciation with  spasm  of  the  levator  tubse  and  tensor  tympani 
muscles  in  hysteria ;  or  as  a  form  of  occupation-neurosis 
after  excessive  use  of  the  voice  in  singers ;  or  as  part  of 
the  picture  of  tic  convulsif.  It  has,  however,  also  been 
observed  in  diseases  of  the  me<lulla.  The  contractions 
of  the  tubal  muscles  sometimes  produce  a  noise  that  may 
be  perfectly  audible  to  a  third  person,  and  is  due  to  the 
opening  and  closing  of  the  tubal  orifice.  Irregular  con- 
tractions of  the  same  kind  may,  of  course,  also  occur. 

SENSORY   DISTURBANCES. 

The  nerves  that  are  concerned  only  with  the  tactile 
sense  may  present  anesthetic,  hypesthetic,  hyperesthetic, 
and  paresthetic  functional  disturbances. 

Anesthesia  of  the  nose,  when  not  of  hysteric  origin, 
is  due  to  some  interruption  in  the  course  of  the  trigeminal 
nerve,  and  is,  therefore,  chiefly  observed  when  branches 
of  that  nerve  have  been  destroyed  during  an  operation. 
The  loss  of  tactile  sense  in  the  skin  and  mucous  mem- 
brane is,  however,  less  noticeable  than  is  the  interruption 
in  the  reflex  arc,  so  that  the  sneezing  and  lacrimal  reflexes 
in  the  affected  area,  which  is  nearly  always  found  to  one 
side  of  the  nose,  are  abolished. 


SENSORY  DISTURBANCES.  187 

Anesthesia  of  the  pharynx  is  a  more  serious  con- 
dition. It  may  he  due  to  the  same  causes  as  paralysis  of 
the  pliarynx,  and  occurs  also  as  a  residt  of  the  extreme 
desiccating  effect  incident  to  cholera,  diabetes,  and  various 
forms  of  enteritis.  It  is  particularly  grave  when  the 
deeper  portions  of  the  pharynx  are  involved.  In  the 
upper  regions  of  the  pharynx  anesthesia  is  of  no  particular 
consequence,  because  the  movement  of  deglutition,  when 
once  begun,  is  automatically  propagated  to  the  palate, 
whereas  closure  of  the  larynx  during  deglutition  is 
effected  solely  by  reflex  innervation,  and,  therefore,  pre- 
supposes the  sensory  integrity  of  the  deeper  portions  of 
the  pharynx  and  of  the  tissues  about  the  superior  aperture 
of  the  larynx.  It  has  been  found  by  experience  that 
solid  morsels  of  food  and  fluids  are  most  liable  to  get  into 
the  larynx,  hence  the  food  in  such  cases  should  be  in 
the  main  semisolid  or  gelatinous ;  in  extreme  cases  arti- 
ficial feeding  may  have  to  be  employed  exclusively. 
Systematic  mechanical  cleansing  of  the  mouth  is  nec- 
essary. The  causal  treatment  is  the  same  as  that  for 
paralysis. 

The  hypesthesia  of  the  pharynx  resulting  from 
the  habitual  use  of  very  hot,  very  cold,  and  highly  sea- 
soned foods  and  beverages,  like  the  hypesthesia  of  the 
mucous  membrane,  which  is  due  principally  to  the  irrita- 
tion of  snuff  and  other  constantly  repeated  forms  of  irrita- 
tion, is  not  without  significance.  In  the  pharynx  dimin- 
ished sensibility  destroys  the  natural  protection  against 
the  introduction  of  injurious  substances  which  develop 
their  harmful  influence  in  the  lower  portions  of  the  di- 
gestive tract.  This  is  shown  by  the  frequency  of  gastric 
ulcers  in  cooks,  who  are  in  the  habit  of  tasting  very  hot 
dishes,  and  by  the  wide  prevalence  of  gastric  catarrh  in 
certain  countries  where  the  inhabitants  habitually  use  ice 
along  with  excessively  hot  and  highly  seasoned  dishes. 
In  the  same  way  loss  of  sensibility  in  the  nose  interferes 
with  the  normal  reflex  act  of  sneezing  and  the  reflex 
engorgement  of  the  erectile  tissues  which   protect  the 


188     DISEASES  OF  THE  NERVES  AND  MUSCLES. 

deeper  air-passages  against  the  entrance  of  dust  and  of 
larger  foreign  bodies. 

Hyperesthesia,  or  excessive  sensibility  to  ordinary 
sensory  irritants,  is  observed  in  some  individuals,  and 
causes  them  to  react  to  an  excessive  degree  either  by  pain 
or  by  the  performance  of  certain  reflex  acts  which,  under 
normal  circumstances,  would  not  be  called  into  action. 
Thus  many  persons  are  painfully  affected  by  cold  air  or 
air  containing  a  small  admixture  of  pungent  substances, 
and  at  once  react  with  sneezing  and  lacrimation.  Hyper- 
esthesia in  the  pharynx  produced  by  psychic  influences, 
such  as  the  fear  of  vomiting,  is  too  well  known  to  every 
physician  as  a  troublesome  obstacle  to  examination  to  need 
any  special  description.  This  variety  includes  the  morn- 
ing nausea  or  vomiting  which  attends  the  abuse  of  alcohol 
or  tobacco. 

Paresthesia  rests  on  a  purely  neurotic  basis  (hysteria, 
hypochondriasis,  or  neurasthenia),  and  assumes  a  great 
variety  of  forms,  such  as  the  feeling  as  of  a  foreign 
body,  or  the  fancied  presence  of  diseased  areas  in  the 
pharynx  and  in  the  throat.  It  is  particularly  apt  to  take 
the  form  of  incorrect  localization  of  affections  that  are 
really  present,  but  at  some  other  place.  The  last-men- 
tioned form  is  exceedingly  common,  as  the  ability  to 
localize  a  sensation  in  the  pharynx  is  very  imperfect.  The 
first-mentioned  variety,  on  the  other  hand,  is  as  rare  in 
fact  as  it  is  common  in  diagnosis,  because  most  sensations 
of  this  kind  depend  not  on  lesions  of  central  origin,  but 
on  actual  structural  affections,  which  are,  naturally,  diffi- 
cult to  find.  The  diagnosis  of  "  nervous "  paresthesia 
must,  therefore,  be  made  only  after  every  possible  basal 
ccmdition  has  been  excluded,  and  when  other  signs  point- 
ing to  the  above-mentioned  causes  are  present. 

The  treatment,  it  need  hardly  be  said,  is  purely 
psychic. 

It  is  proper  at  this  point  to  mention  neuralgia,  since 
it  in  a  sense  also  represents  an  abnormality  of  sensation. 
It  may  form  part  of  a  general  trigeminal  neuralgia,  inas- 


DISTURBANCES  OF  SPECIAL  SENSE.  189 

much  as  this  nerve  supplies  the  oral  and  pharyngeal  mu- 
cous membrane,  and  it  may  api>ear  as  an  independent 
condition  in  the  form  of  gfossodynia.  This  affection, 
which  occurs  chiefly  in  middle  age,  may  be  due  simply  to 
neuritis  of  the  glossopharyngeus  or  of  the  trigeminus ;  it  is, 
however,  constant  in  character,  and  in  this  respect  differs 
from  neuralgia,  which  tends  to  periodicity,  so  that  one 
cannot  help  thinking  of  a  hypochondriac  or  hysteric  origin. 
Accordingly,  the  results  of  treatment  are  extremely  vari- 
able, all  efforts  in  some  cases  being  unsuccessful,  while  in 
others  the  effect  is  magical. 


DISTURBANCES   OF   SPECIAL  SENSE. 

Disturbances  of  taste  and  smell  practically  always  occur 
in  association  one  with  the  other,  as  the  ability  to  perceive 
fine  distinctions  in  taste,  such  as  the  aroma  of  food  and 
drink,  presupposes  the  cooperation  of  the  sense  of  smell. 
The  perceptive  powere  of  the  unaided  organs  of  taste  are 
limited  to  the  distinction  between  sweet  and  bitter,  salt 
and  sour,  or,  at  most,  to  the  perception  of  what  is  known 
as  a  metallic  taste ;  and,  as  a  matter  of  experience,  dis- 
turbances of  this  character  are  extremely  rare. 

It  is  only  the  latter  that  can  be  designated  as  ag'eusia 
and  parageusia.  (The  excessive  irritability  described 
as  hyperageusia  probably  belongs  to  the  domain  of  physi- 
ology, and  also  depends,  in  the  main,  on  the  olfactory 
element  in  the  sense  of  taste.)  Ageusia  in  this  restricted 
sense  may  be  due  to  mechanical  causes  preventing  excita- 
tion of  the  nerve-endings  by  the  presence  of  severe  oral 
catarrh  or  a  thick  coating  on  the  tongue — the  so-called 
pasty  taste.  It  may  be  due  to  paralysis  of  the  sensory 
nerves,  the  trigeminus  and  glossopharyngeus,  and  especi- 
ally of  the  chorda  tympani  and  the  trunk  of  the  facial 
ners'^e.  Neuritis  of  the  facial  and  chorda  tympani  of  rheu- 
matic or  inflammatory  origin,  as  in  otitis  media,  may  pro- 
duce parageusia,  consisting  in  the  inability  to  distinguish 
sweet  from  bitter  and  salty  from  sour.     It  need  hardly 


190     DISEASES  OF  THE  NERVES  AND  MUSCLES. 

be  mentioned  that  central  paralysis  of  these  nerves  will 
have  the  same  effect.  Unilateral  disturbances  of  tlie  sense 
of  taste  are  almost  certainly  due  to  neuritis. 

Anosmia  and  aromatic  ageusia  may  be  due  to  the 
presence  of  some  mechanical  ol)stacles  preventing  the  air- 
current  from  reaching  tiie  olfactory  region,  or  to  the  fact 
that  the  air-current  fails  to  follow  its  normal  course 
through  the  middle  meatus,  and  passes,  instead,  along  the 
floor  of  the  nose,  as  in  the  presence  of  abnormally  wide 
nasal  cavities.  Insensibility  to  odors  reaching  the  olfac- 
tory cells  in  the  normal  way  is  due  to  loss  of  function  of 
the  olfactory  cells  from  constant  bathing  of  the  olfactory 
membrane  with  pus,  or  constant  irritation  of  strong  vapors 
or  perfumes.  Finally,  a  central  anosmia  may  be  produced 
by  injuries,  inflammations,  or  tumors  of  the  olfactory 
bulbs  and  of  the  trunk  of  the  olfactory  nerve,  but  the 
diagnosis  of  this  condition  is  possible  only  when  other 
basal  symptoms  are  present,  or  at  the  autopsy.  Temporary 
anosmia  is  sometimes  observed  in  the  course  of  acute  infec- 
tions. 

The  prognosis  in  anosmia  due  to  the  presence  of  some 
mechanical  obstacle,  of  course,  depends  on  the  possibility 
of  removing  that  obstacle,  just  as  the  cure  of  a  disturb- 
ance due  to  suppurations  requires  the  cessation  of  the 
suppurative  process.  But  even  when  the  immediate  cause 
can  be  removed,  the  atrophy  due  to  prolonged  disuse  often 
proves  irreparable. 

The  term  parosmia,  or  aromatic  parageusia,  is  used 
when  certain  odors  awaken  a  sensation  different  from  that 
which  is  produced  under  normal  conditions.  These  per- 
verse and,  as  a  rule,  disagreeable  sensations  depend 
chiefly  on  a  hysteric  cause.  They  occur  not  infrequently 
during  convalescence  from  influenza,  when  they  probably 
depend  on  direct  injury  to  the  olfactory  membrane.  The 
phenomenon  is  sometimes  observed  in  all  kinds  of  central 
and  psychic  diseases,  where  they  must  be  distinguished, 
as  always,  from  spontaneous  olfactory  hallucinations. 
Conversely,  a  diagnosis  of  hallucination  is  not  justifiable 


REFLEX  AND  REMOTE  SYMPTOMS.  191 

ill  every  case  when  the  individual  complains  of  a  bad 
smell  which  is  not  perceived  by  others,  for  a  so-called 
subjective  odor  may  be  due  to  some  decomposition  process 
in  the  depths  of  the  nose,  particularly  in  the  accessory 
minuses,  the  source  of  the  odor  being  so  situated  that  the 
latter  cannot  reach  the  exterior.  As  a  matter  of  fact,  this 
condition,  which  is  known  as  cacosmia,  usually  has  an 
objective  cause, 

VASOMOTOR   AND  SECRETORY   DISTURBANCES. 

While  the  vasomotor  nerves  of  the  nose  react  to  any  irri- 
tation of  the  mucous  membrane  by  congestion  (see  p.  195), 
tliat  phenomenon  is  also  observed  as  a  concomitant 
symptom  in  congestion  of  the  genital  organs.  The  latter 
have  already  been  referred  to  elsewhere  (see  p.  182);  it 
manifests  itself  in  alternate  swelling  and  shrinking  of  the 
erectile  tissue.  The  phenomenon  is  accompanied  by  a 
simultaneous  discharge  of  watery  mucus  from  the  nose 
and  by  increased  salivation,  depending  partly  on  periph- 
eral, olfactory,  thermic,  and  gustatory  stimuli,  and  partly 
on  nervous  excitation  in  predisposed  individuals.  Such 
persons  sometimes  suifer  from  a  sudden  outpouring  of 
enormous  quantities  of  mucus  from  the  nose — so-called 
vasomotor  nasal  hydrorrhea,  which  may  in  an  indi- 
vidual case  have  to  be  carefully  distinguished  from  the 
sudden  discharge  of  secretions  retained  in  an  accessory 
sinus.  True  nervous  hydrorrhea  yields  to  atropin  and  to 
general  nerve  treatment. 

REFLEX   AND   REMOTE  SYMPTOMS. 

Any  unusual  stimulus  acting  on  any  portion  of  the 
upper  respiratory  passages  calls  forth  a  defensive  move- 
ment on  the  part  of  the  muscles  of  respiration  similar  to 
that  exerted  to  prevent  the  entrance  of  a  foreign  body. 
The  diaphragm  and  the  muscles  of  the  thorax  perform  a 
respiratorv  movement  or  become  arrested  for  some  time 
in  the  expiratory  position ;  the  glottis  closes ;  the  muscu- 


192     DISEASES  OF  THE  NERVES  AND  MUSCLES. 

lature  of  the  bronchial  tree  contracts  ;  cough  is  produced 
when  the  irritation  aifects  the  larynx  or  the  deeper  por- 
tions of  the  pharynx  ;  sneezing,  when  the  nose  or  the 
extreme  anterior  portion  of  the  palate  has  been  irritated. 
These  defensive  movements  are  sometimes  produced  also 
in  response  to  cutaneous  stimuli,  as  appears  from  the  fact 
that  this  normal  reflex  process  is  very  apt  to  be  started 
in  some  abnormal  way ;  and,  on  the  other  hand,  it  indi- 
cates that  the  physiologic  is  separated  from  the  pathologic 
by  a  very  narrow  boundary.  The  alteration  in  the  re- 
flexes presupposes  a  special  predisposition  of  the  con- 
ducting nerves  that  make  up  the  reflex  arc,  or  of  the 
entire  individual. 

Peripheral  stimuli  which  do  not  in  the  least  affect 
normal  individuals  produce  spasm  of  the  bronchial  and 
other  respiratory  muscles,  asthma,  or,  in  other  cases, 
paroxysmal  attacks  of  coughing  and  sneering. 
Such  is  the  simple  basis  of  the  so-called  reflex  neuroses 
of  the  nose  and  pharynx.  The  initial  stimulus  may  be 
derived  from  repeated  tickling,  irritation  of  the  mucous 
membrane  by  the  contact  of  other  movable  parts,  such, 
for  instance,  as  a  small  polypus,  or  from  the  changes 
which  are  presumed  to  take  place  in  the  outermost  nerve- 
endings  of  the  turbinates  and  septum,  which  may  start 
the  reflex  act  even  after  a  slight  stimulus,  such  as  a 
thermic  impression,  for  instance,  well  within  the  domain 
of  the  normal.  One  of  the  most  frequent  causes,  and  one 
which  is  very  commonly  overlooked,  especially/  in  the  case  of 
asthma,  is  the  constant  flow  of  nasal  discharges  into  the 
pharynx,  so  common  in  conditions  associated  with  excess- 
ive nasal  secretion.  The  laborious  and  often  fruitless 
efforts  to  prevent  the  accumulation  of  this  secretion,  to- 
gether with  the  general  irritation  due  to  the  chemical  and 
mechanical  causes,  readily  bring  on  the  expiratory  reflex. 

In  addition  to  these  local  areas  of  excessive  irritation 
and  a  general  predisposition,  there  is  in  many  cases  a 
temporal  and  topographic  element,  the  attacks  coming  on 
at  certain  seasons  of  the  year  or  hours  of  the  day,  and  in 


REFLEX  AND  REMOTE  SYMPTOMS.  193 

certain  localities.  In  a  general  way  the  bad  season  of 
the  year  and  an  inclement,  dusty  climate  are  predisposing 
factors,  but  it  is  particularly  characteristic  of  the  neuras- 
thenic nature  of  the  attacks  that  they  do  not  take  place 
in  many  individuals  under  circumstances  which  are  ap- 
parently unfavorable,  while  they  do  take  place  in  the 
most  unexpected  manner  when  the  surroundings  must  be 
regarded  as  mild  and  particularly  free  from  irritation. 
Hence  the  conclusions  to  be  drawn  from  cocainizafion  in 
regard  to  the  connection  between  the  irritation  of  certain 
portions  of  the  mucous  membrane  have  only  a  relative 
value.  If  anesthetization  of  a  certain  area  in  the  nose  or 
pharynx  aborts  or  mitigates  an  attack  of  asthma,  that  area 
may  be,  as  a  rule,  regarded  as  the  cause  of  the  trouble, 
but  the  connection  between  the  two  events  is  not  suffi- 
ciently constant  to  form  a  trustworthy  basis  for  a  prog- 
nosis. Conversely,  the  cocainization  of  certain  areas, 
especially  in  the  pharynx,  sometimes  has  no  momentary 
effect  whatever,  because  the  irritation  is  not  superficial 
enough,  whereas  if  the  condition  responsible  for  the  con- 
stant irritation  of  the  corresponding  portion  of  the  mucous 
membrane  is  removed,  the  asthma  is  improved  or  even 
cured.  [It  has  been  pointed  out  that  the  addition  of 
2  per  cent,  of  pure  sodium  sulphate  to  a  5  per  cent, 
solution  of  cocain  greatly  increases  the  penetrative  power 
of  the  latter  by  dissolving  the  albuminous  elements 
of  the  secretion  covering  the  mucosa.  The  anesthetic 
efifects  of  this  combination  are  equal  to  those  of  a  10 
per  cent,  solution  not  thus  fortified.  The  danger  of 
constitutional  symptoms  is  thus  lessened,  and  the  use  of 
the  remedy  attended  with  less  expense,  a  factor  worthy 
of  consideration  in  institution  practice. — Ed.]  Hence  the 
nasopharyngeal  treatment  of  asthma  is  in  every  case  abso- 
lutely empiric.  It  serves  merely  to  exclude  from  the  causa- 
tion any  areas  that  are  evidently  pathologic,  or  may  be 
suspected  of  being  the  initial  point  of  irritation  from  the 
effects  of  an  application  of  cocain  ;  the  fact  that  it  is  suc- 
cessful has  no  prognostic  value.  If  treatment  is  instituted 
i3 


194     DISEASES  OF  THE  NERVES  AND  MUSCLES. 

at  all,  it  should  be  done  without  promising  the  patient 
anything  whatsoever.  It  includes  merely  the  removal  or 
mitigation  of  oversecretion,  which  may  often  be  accom- 
plished by  the  systematic  use  of  nasal  sprays  and  the 
cautious  application  of  the  cautery  to  areas  found  by  the 
cocain  test  to  be  irritable.  These  sensitive  areas  are 
found  chiefly  on  the  tuberculum  septi,  the  upper  border 
of  the  inferior  turbinate,  and  the  granulations  in  the 
pharynx.  It  includes  also  the  removal  of  movable  polypi 
and  other  tumors  capable  of  tickling  the  mucous  mem- 
brane, and  the  restoration  of  free  nasal  ventilation.  The 
senseless  practice  of  indiscriminate  cauterization  in  the 
hope  that  it  may  do  some  good,  and  especially  the  injudi- 
cious warfare  against  small  excrescences  on  the  septum  and 
septal  deviations,  cannot  be  too  sweepingly  condemned. 
The  treatment  of  the  latter  is  justified  only  when  the 
septum  is  in  contact  with  the  inferior  or  with  the  middle 
turbinate.  The  local  treatment  must  be  supported  by 
psychic  and  general  invigorating  measures ;  pneumo- 
therapy  is  not  to  be  neglected ;  and  potassium  iodid  must 
be  given  in  considerable  doses.  The  result  is  quite  often 
satisfactory,  but  in  many  cases  treatment  is  altogether 
without  avail,  and  there  seems  to  be  no  way  of  deter- 
mining the  results  of  treatment  beforehand. 

The  coughing  and  sneering  reflexes  are  less  fre- 
quent but  more  distressing  both  to  the  patient  and  to  the 
physician,  unless  recovery  promptly  ensues  after  definite 
points  of  irritation,  such  as  the  septum,  the  turbinates,  the 
lingual  glands,  and  the  granulations  have  been  excluded  ; 
the  condition  rests  on  a  neurasthenic  or  hysteric  founda- 
tion, and  all  efforts  at  cure  are  unavailing. 

It  is  ever  to  be  borne  in  mind  that  any  one  of  these 
mucous  membrane  reflexes  may  be  induced  from  other 
portions  of  the  body,  as,  for  instance,  from  the  external 
auditory  meatus.  The  sexual  system  plays  a  very  impor- 
tant role,  both  as  a  direct  cause  of  the  disease  and  as  an 
adjuvant  in  the  process  when  the  point  of  irritation  is 
situated  in  some  other  portion  of  the  body. 


REFLEX  AND  REMOTE  SYMPTOMS.  195 

The  reflex  irritation  may  affect  not  only  the  respiration, 
but  also  the  action  of  the  heart  by  exciting  or  paralyzing 
the  pneumogastric  nerve. 

Cardiac  neuroses,  tachycardia  and  bradycardia, 
arhytiimia,  and  even  stenocardiac  attacks  may  be  pro- 
duced by  mechanical  and  other  irritation  of  the  nasal 
mucous  membrane.  In  a  few  instances  Basedow's 
symptom-complex  has  been  observed  to  disappear  after 
treatment  of  the  nasal  affection. 

It  is,  however,  better  to  accept  any  such  results  as 
these  thankfully,  rather  than  count  upon  them,  not  to 
speak  of  promising  them  beforehand. 

The  last  group  of  reflexes  include  the  vasomotor  and 
secretory  phenomena — namely,  erythema  and  edema  of 
the  nose  and  cheeks ;  permanent  hyperemia  of  these 
parts ;  hyperemia  of  the  erectile  tissue  in  the  interior  of 
the  nose  when  the  disease  focus  is  situated  in  some  other 
portion  of  the  body  :  hyperemia  and  catarrh  of  the  con- 
junctiva and  deeper  portions  of  the  eye,  together  with 
the  symptoms  of  asthenopia  and  other  functional  disturb- 
ances. These  last-named  reflexes  commonly  accompany 
anv  severe  chronic  inflammation  in  the  interior  of  the 
nose. 

Reflex  disturbances  are  to  be  carefully  distinguished 
from  remote  affections,  the  latter  being  painful  sensations 
occurring  in  areas  near  the  oropharyngeal  cavity  or  in 
some  remote  region  of  the  body.  Their  origin  is  explained 
by  the  radiation  of  a  sensory  irritation  acting  on  a  definite 
point  in  the  distribution  of  a  nerve  to  other  points  sup- 
]>lied  by  the  same  nerve  or  by  a  neighboring  system  of 
nerves.  Or  it  may  be  assumed  that,  owing  to  general 
hypersensitiveness,  an  irritation  which,  under  other  cir- 
cumstances, would  not  be  noticed,  degenerates  into  a 
painful  sensation  in  some  remote  sensory  region.  Ex- 
amples of  the  first  variety  are  found  in  the  occipital 
headache  that  accompanies  inflammation  of  the  frontal 
sinus ;  the  supra-orbital  pain  of  empyema  of  the  antrum 
of  Hi'ghmore ;  toothache  in  the  upper  and  lower  jaws  in 


196     DISEASES  OF  THE  NERVES  AND  MUSCLES. 

diseases  aifecting  the  distribution  of  the  superior  dental 
nerve,  and  particularly  the  symptom  produced  by  hyper- 
esthesia of  tiie  nerve-endings  in  the  nose  on  tlie  inferior 
turbinate  and  tuberculum  septi.  Examples  of  the  second 
class,  which  constitute  the  true  distant  symptoms,  are  gas- 
tralgia,  coxalgia,  dysmenorrhea,  and  a  host  of  similar  un- 
definable  painful  sensations  which  disappear  after  cocaini- 
zation  of  any  portion  of  the  nose  or  pharynx.  But  from 
the  explanation  of  tiieir  origin  that  has  been  offered,  it 
follows  tiiat  there  can  be  no  logical  connection  between 
symptoms  of  this  kind  and  the  point  of  irritation.  It  is, 
at  least,  certain  that  no  connection  can  be  established  be- 
tween a  definite  region  of  the  nose  and  dysmenorrhea,  for 
example;  or  another  region  of  the  nose  and  gastralgia. 
Such  relation  as  exists  depends  on  the  simultaneous  irri- 
tation of  widely  separated  regions  often  by  very  different 
causes,  and  the  fact  that  irritation  of  the  general  sensibility 
through  one  or  the  other  of  the  correlated  regions  is  neces- 
sarily accompanied  by  irritation  of  the  other.  The  basal 
disease  may  be  either  a  simple  neurotic  affection  or  a  local 
process  of  considerable  severity,  which  is  more  likely  to 
be  overlooked  or  misinterpreted  if  the  physician  is  a  slave 
to  his  preconceived  opinions,  unless  the  diagnosis  is  abso- 
lutely clear  from  the  outset.  The  author  recalls  a  case 
of  gastric  ulcer  which  was  never  suspected  until  its  pres- 
ence was  revealed  by  a  fatal  hemorrhage ;  the  gastralgia 
which  had  existed  for  a  long  time  had  been  treated  as  a 
nervous  symptom  and  had  promptly  yielded  to  cocainiza- 
tion  of  the  inferior  turbinate.  The  interdependence  of 
genital  and  nasal  affections  is  even  more  common  on 
account  of  the  similarities  of  the  vasomotor  apparatus  in 
both  regions,  and  they,  therefore,  demand  even  more 
careful  scrutiny.  The  predisposition  to  neurasthenic 
symptoms  of  this  kind  may  be  greatly  enhanced  by  tlie 
venous  and  lymphatic  congestion  at  tiie  base  of  the  brain, 
which  has  been  described  in  connection  with  nasal  obstruc- 
tion (see  pp.  18  and  26). 

It  follows,  from  what  has  been  said,  that  the  diagnosis 


TRAUMATISMS  OF  THE  OROPHARYNX.         197 

of  a  true  distant  affection  must  be  made  with  the  greatest 
caution ;  and  in  the  matter  of  treatment,  it  would  be  well 
to  promise  the  patient  practically  nothing  and  to  confine 
one's  self  to  a  policy  of  non-interference,  since  too  much 
treatment  only  tends  to  increase  the  state  of  hypochon- 
driasis. 

The  prognosis  and  treatment  of  direct  radiating  pains, 
on  the  other  hand,  are  much  more  favorable,  because  the 
pains  are  usually  due  to  distinct  changes  in  the  correspond- 
ing region.  Active  local  interference  is,  therefore,  indi- 
cated. Any  conspicuous  local  affection,  such  as  a  suppu- 
ration, an  ulcer,  or  a  tumor,  is  always  a  welcome  point  of 
attack ;  but  a  mere  suspicious  or  slightly  affected  spot  on 
the  turbinates  or  septum  should  not  be  regarded  and 
treated  as  the  source  of  radiating  headache,  unless  the 
characteristic  pain  can  be  elicited  definitely  by  touching 
these  points  with  the  probe,  and  disappears  after  they 
have  been  anesthetized.  The  same  precautions  should  be 
used  in  the  investigation  of  the  local  cause  of  a  distant 
affection.  The  offending  areas  of  the  mucous  membrane 
are  best  cauterized  with  trichloracetic  acid,  and  if  that 
fails,  with  the  galvanocautery  puncture. 


TRAUMATIC,   MECHANICAL,   CHEMICAL,  AND  THER- 
MIC INJURIES. 

Traumatisms  of  the  oropharynx  and  of  the  nose 
do  not  differ,  as  regards  symptomatology  and  treatment, 
from  ordinary  surgical  injul-ies.  It  is  well,  however,  to 
remember  that  injuries  of  the  upper  mucous  membranes 
heal  rapidly  on  account  of  the  abundant  blood-supply. 
Complications  may  occur  whenever  the  opportunity  is 
given  for  neighboring  portions  of  the  mucous  membrane 
to  form  adhesions ;  hence  prophylactic  measures,  consist- 
ing principally  in  the  use  of  a  tampon,  play  an  important 
role  in  the  treatment.  Later  on  the  question  of  a  plastic 
operation  or  resection  may  have  to  be  considered  and  must 
be  decided  on  general  surgical  principles. 


198  INJURIES. 

lujuries  of  the  septum  in  certain  respects  represent 
a  special  class.  A  blow  of  moderate  severity  on  the  bridge 
of  the  nose,  at  the  level  of  the  cartilaginous  septum,  is 
followed  by  hemorrhage  between  the  perichondrium  and 
the  quadrilateral  cartilage  of  one  or  both  sides  of  the 
nose.  If,  as  is  usually  the  case,  the  hemorrhage  is  bilate- 
ral, the  cartilage  is  deprived  of  its  nutrition  and  soon 
undergoes  necrosis;  but  even  when  a  unilateral  hema- 
toma results,  necrosis  in  the  form  of  the  so-called  "  lorg- 
nette nose"  follows,  because  the  extravasation  becomes 
infected  through  the  contused  or  lacerated  mucous  mem- 
brane and  undergoes  suppuration.  Most  cases  come  under 
observation  during  this  stage — the  stage  of  septal  abscess. 
Up  to  this  time  the  symptoms  are  insignificant,  but  now 
sharp  pain  and  a  sense  of  heat  are  complained  of,  with  a 
moderate  degree  of  obstruction.  In  the  region  of  the 
tuberculum  septi  on  one  or  both  sides  a  soft  spheric  promi- 
nence is  then  discovered,  which  should  at  once  be  incised 
and  packed  with  a  thin  strip  of  gauze,  or,  if  suppuration 
has  not  yet  set  in,  the  clot  may  be  turned  out,  and  the 
mucous  membrane  held  in  apposition  with  the  cartilage 
by  loosely  packing  the  superior  nasal  meatus.  If  por- 
tions of  the  cartilage  have  already  become  necrotic,  they 
should  be  removed  ;  otherwise  the  treatment  should  be  as 
conservative  as  possible. 

If  the  injury  has  been  severe  and  has  involved  the  tur- 
binates, adhesions  occasionally  form — as,  for  instance,  in 
the  condition  illustrated  in  Fig.  34.  Such  an  adhesion, 
like  all  other  adhesions  between  the  turbinates  and  the 
septum,  it  may  be  as  well  to  remark  at  once,  should  be 
treated  on  the  same  principles  as  congenital  adhesions 
(see  p.  212). 

A  caution  in  regard  to  the  diagnostic  significance  of  the 
bitten  tongue  of  the  epileptic  :  it  would  be  wrong  to  infer 
the  existence  of  epilepsy  from  every  injury  of  this  kind, 
as  similar  Avounds  may  be  observed  in  chronic  catarrh  of 
the  mouth  and  in  paralyses,  attributable  to  the  compara- 
tive helplessness  and  hypesthesia  of  the  tongue. 


MECHANICAL  INJURIES.  199 

Mechanical  Injuries. — The  mucous  membranes  are 
so  constantly  exposed  to  mechanical  irritation  tiiat  they 
often  cease  to  react  to  them  altogether.  This  is  especi- 
ally true  in  regard  to  various  forms  of  dust.  But  under 
the  influence  of  a  special  irritability  which  has  never  been 
satisfactorily  explained,  more  intense  efl^ects  are  some- 
times observed.  Typical  phenomena  of  this  kind  are 
observed  in  so-called  summer  catarrh,  having  its  origin  in 
the  pollen  of  flowers  and  grass,  the  chief  representative 
of  which  is  hay-fever.  During  the  season  when  these 
vegetable  substances  are  active,  the  predisposed  individual 
is  subject  to  attacks  of  extraordinarily  violent  catarrh  of 


Fig.  34.— Broadening  of  the  right  middle  turbinate  and  adhesion  with  the 
septum  after  fracture  of  the  nose  by  the  kick  of  a  horse.  Congenital  adhesion 
of  the  inferior  turbinate  with  a  spine  on  the  septum. 

the  conjunctivse,  of  the  nose,  and  of  the  pharynx,  charac- 
terized by  paroxysms  of  sneezing  of  unusual  violence  and 
incredible  frequency.  The  catarrh  may  also  extend  to  the 
deeper  mucous  membranes  of  the  respiratory  tract  and 
produce  a  violent  form  of  asthma.  The  number  of  reme- 
dies suggested  for  this  condition  is  enormous,  and  their 
efficacy  is  correspondingly  doubtful.  The  only  hope  of 
relief  is  removal  to  some  region  where  the  particular  form 
of  dust  to  which  the  individual  is  sensitive  is  not  found. 
The  island  of  Heligoland  enjoys  some  reputation  as  a 
resort  for  this  class  of  patients. 

Chemical   Injuries. — The  irritation  from  the  dust 


200  INJURIES. 

of  potassium  chromate,  cement,  tobacco,  and  spices  is  both 
mechanical  and  chemical.  Many  artisans  whose  work 
brings  them  in  contact  with  potassium  chromate  and  cement 
are  found  to  have  traumatic  perforations  of  the  septum, 
the  original  cause  of  which  is  to  be  sought  in  the  itching 
produced  by  these  substances. 

Poisons  circulating  in  the  blood,  chiefly  drugs,  exert  a 
purely  chemical  irritation.  Thus  iodin  gives  rise  to  the 
well-known  coryza  of  iodism,  and,  like  bromin,  to  acute 
stomatitis,  a  characteristic  symptom  of  which  is  a  certain 
whitish  deposit  on  the  gums. 

In  chronic  phosphorus-poisoning  the  toxic  agent,  as  every 
one  knows,  attacks  the  lower  jaw  by  way  of  the  gums 
and  carious  tt^eth,  hence  the  earliest  symptoms  consist  in 
gingivitis  and  alveolar  periostitis.  Mercurial  stomatitis 
has  been  discussed  elsewhere  (see  p.  57).  Of  the  other 
metals,  copper  and  lead  remain  to  be  mentioned.  Both 
produce  changes  in  the  gums.  In  copper-poisoning  these 
changes  extend  quite  deeply,  while  in  lead-poisoning  they 
are  only  superficial. 

Caustic  acids  and  alkalis,  introduced  either  for  thera- 
peutic or  for  suicidal  purposes,  produce  a  direct  chemical 
effect  on  the  mucous  membranes.  In  the  nose  injuries 
of  this  kind  are  practically  always  due  to  surgical  inter- 
vention, because  when  they  are  produced  in  any  other 
way  it  is  usually  by  means  of  excessively  strong  gargles 
or  by  poisons  taken  with  suicidal  intent.  The  lesions 
consist,  in  the  main,  of  whitish  crusts  of  variable 
thickness ;  sulphuric  acid  leaves  brownish-red  or  black 
crusts ;  while  nitric  stains  the  tissues  yellow.  Later  on 
the  crusts  may  become  dark  in  color,  on  account  of 
the  hemorrhage  that  so  often  follows  cauterization  of  the 
tissues. 

Bums  in  the  nose  are  observed  only  after  surgical 
operations.  If  the  operation  was  justified,  there  is  nothing 
more  to  be  said  about  the  course  of  the  injury.  If  oppo- 
site surfaces  have  been  affected,  or  if  the  eschars  are 
allowed  to  remain  in  place  too  long,  organization  takes 


FOREIGN  BODIES.  201 

place  and  adhesions  result.  This  accident  must  be  pre- 
vented by  systematic  use  of  liquid  vaselin  or  the  intro- 
duction of  thin  strips  of  gauze  saturated  in  the  substance. 
[We  have  found  useful  for  this  purpose  narrow  strips  of 
gutta-percha  such  as  is  used  by  dentists  for  a  temporary 
tilling.     It  is  non-irritating  and  non-absorbent. — Ed.] 

In  the  mouth  and  pharynx  burns  are  caused  by  the 
ingestion  of  very  hot  food  and  drink  or  the  inhalation  of 
superheated  gases.  Vesication  is  produced,  but  lasts  so 
short  a  time  that  it  is  rarely  observed.  The  exposed 
mucous  membrane  becomes  covered  with  a  fibrinous  exu- 
date. The  treatment  of  these  injuries  consists  solely  in 
the  application  of  remedies  to  allay  the  pain,  such  as  ice, 
cocain,  and  orthoform,  and  in  saving  as  much  of  the  tissue 
as  possible. 

FOREIGN  BODIES. 

Foreign  bodies  may  be  classified  as  organic  and  in- 
organic. One  form  of  inorganic  foreign  bodies  occur- 
ring in  the  ducts  of  salivary  glands  and  in  the  crypts  of 
the  tonsils  has  already  been  described  in  the  concretions 
and  calcareous  accumulations  known  as  salivary  and  ton- 
sillar "  calculi." 

Similar  calculi  occur  in  the  nose,  where  they  consist 
chiefly  of  calcium  phosphate.  The  calculi  vary  in  size, 
and  usuallv  have  as  a  central  nucleus  a  cherry-stone  or 
some  other' small  object  that  children  are  so  fond  of  intro- 
ducing into  their  noses.  In  fact,  most  foreign  bodies  are 
introduced  into  the  nose  in  this  way ;  they  are  often  of 
incredible  size,  and  of  such  great  variety  that  they  might 
fitlv  grace  the  shelves  of  a  museum.  Not  infrequently  per- 
cussion caps  and  other  parts  of  a  rifle  or  even  bullets  may 
be  found  in  the  nose  and  in  its  accessory  sinuses  as  the 
result  of  an  explosion  of  some  kind.  Injuries  received  m 
battle  also  contribute  a  contingent  to  this  class  of  foreign 

bodies. 

In  the  mouth  and  pharynx  foreign  bodies  that  have 
been  held  between  the  lips 'are  either  aspirated  with  the 


202  FOREIGN  BODIES. 

air-current  or  swallowed  along  with  food.  As  a  smooth 
object  usually  penetrates  to  the  deeper  portions,  the  foreign 
bodies  that  concern  us  in  this  connection  consist  chiefly 
of  needles,  fish-bones,  and  similar  objects.  Particles  of 
gastric  contents,  finally,  may  be  projected  into  the  naso- 
pharynx during  the  act  of  vomiting. 

The  consequences  of  the  introduction  of  a  foreign  body 
are  manifold.  The  foreign  body  may  remain  in  situ  for 
some  time  without  giving  rise  to  any  symptoms ;  but,  as 
a  rule,  a  violent  local  inflammation  results.  Sharp  bodies 
may,  by  penetrating  the  tissues  or  at  least  opening  the 
way  for  infection,  give  rise  to  erysipelas ;  abscess  with 
erosion  of  the  surrounding  bone,  as  on  the  septum,  in  the 
floor  of  the  nose,  and  in  the  cervical  portion  of  the  v^erte- 
bral  column ;  or  deep  abscesses  burrowing  in  various 
directions.  Severe  hemorrhage  also  may  be  produced. 
Sometimes  the  foreign  body  becomes  loose  of  its  own 
accord  and  is  expelled,  or  it  may  wander  into  distant 
portions  of  the  body  and  prove  fatal  in  this  way,  although 
in  most  cases  the  offending  object  is  later  removed  artifici- 
ally. 

Symptoms  due  to  a  foreign  body  in  the  nose  are  almost 
always  unilateral,  and  consist  in  obstruction  ;  purulent, 
usually  fetid,  secretion,  frequently  mixed  with  blood  ;  and 
violent  pain  referred  to  various  portions  of  the  nose,  ac- 
cording to  the  seat  and  size  of  the  foreign  body.  As  these 
symptoms  resemble  the  symptoms  of  infectious  processes, 
especially  syphilis,  and  as  the  reactive  inflammatory  and 
proliferative  ]>rocesses,  such  as  bleeding,  granulations,  and 
polypoid  tumors,  are  quite  capable  of  simulating  the 
appearances  either  of  syphilis  or  of  malignant  tumors,  the 
history  of  the  accompanying  circumstances  needs  to  be 
carefully  weighed.  The  surface  of  the  foreign  body  being 
usually  rough,  like  that  of  necrotic  bone,  the  sound  elicited 
with  the  probe  is  very  similar  in  both  cases,  while  incrus- 
tations and  aberrant  teeth,  owing  to  their  grayish-white 
color,  are  even  more  apt  to  be  mistaken  for  necrotic 
bone. 


TREATMENT.  205 

Foreign  bodies  in  the  mouth  and  pharynx  are  less 
apt  to  produce  these  deceptive  symptoms;  but,  on  the 
other  iiand,  they  may  slip  under  the  mucous  membrane, 
especially  such  objects  as  needles  and  fish-bones,  or  they 
may  remain  hidden  from  view  in  one  of  the  recesses  of 
the  oropharynx.  Pain  and  the  sense  of  the  presence  of  a 
foreign  body  make  their  appearance  early,  but  they  per- 
sist for  some  time  after  spontaneous  expulsion  of  the 
foreign  body,  either  as  the  result  of  the  actual  changes  or 
for  psychic  reasons,  and  finally  they  may  even  be  produced 
by  the  mere  dread  that  a  foreign  body  may  have  effected 
an  entrance. 

It  follows  that  the  diagnosis  rests  chiefly  on  the  direct 
demonstration  of  a  foreign  body.  If  it  is  seen  at  once, 
the  matter  is  settled  ;  but  if  not,  the  nose  must  be  explored 
with  a  probe.  In  any  case  the  pharynx  should  be  pal- 
pated, because  a  pointed  object  may  penetrate  so  far  into 
the  tissue  that  its  external  extremity  can  be  detected  only 
by  the  palpating  finger.  Care  is  necessary  to  avoid  dis- 
placing the  foreign  body  or  forcing  it  deeper  into  the 
tissues.  If  nothing  is  found  by  these  methods,  or  if,  for 
instance,  the  examination  of  the  nose  leaves  the  surgeon 
in  doubt  as  to  whether  he  has  to  deal  with  a  foreign  body 
or  with  beginning  necrosis  of  the  bone,  additional  infor- 
mation may  be  obtained  by  means  of  the  Rontgen  rays, 
which  are  particularly  useful  in  demonstrating  the  presence 
of  foreign  bodies. 

The  treatment  must,  of  course,  begin  with  the  ex- 
traction of  the  offending  object.  I  cannot  indorse  the 
various  methods  of  expulsion  by  means  of  a  current 
of  air  which  have  been  recommended  in  the  case  of  the 
nose,  as  they  are  usually  ineffective,  and  almost  never 
without  danger  to  the  ear.  Instrumental  extraction  should 
be  tried  in  every  case,  either  after  careful  cocainization 
or,  in  little  children  and  in  difficult  cases,  with  a  general 
anesthetic.  In  the  nose  it  is  important  to  introduce  the 
instrument  behind  the  foreign  body,  so  as  to  push  it  for- 
ward; a  bent  curet  (Fig.  13),  a  wire  loop,  a  bent  probe, 


204  FOREIGN  BODIES. 

or  some  other  similar  instrument  may  be  utilized  for  the 
purpose,  according  to  the  conditions  of  the  case.  If  the 
foreign  body  is  to  be  seized  from  in  front,  either  in  the 
nose  or  in  the  nasopharyngeal  cavity,  instruments  should 
be  used  which  would  make  it  impossible  for  the  foreign 
body  to  escape  and  be  pushed  farther  into  the  cavity  ;  the 
best  instrument  is,  therefore,  a  sharp  bone  forceps.  Large 
soft  bodies,  like  swollen  cereals  and  the  like,  may,  if 
necessary,  be  broken  up  in  situ. 

In  extreme  cases  an  external  operation,  freely  exposing 
the  cavity  that  contiiins  the  foreign  body,  may,  of  course, 
have  to  be  considered.  If  the  foreign  body  is  in  one  of 
the  accessory  sinuses,  such  an  operation  can  scarcely  be 
dispensed  with,  although  occasionally  a  small  object  that 
is  easily  seized  may  be  extracted  from  the  antrum  with  a 
wire  snare  introduced  through  an  already  existing  opera- 
tive fistula  or  an  opening  in  the  alveolar  process. 

Organic  foreign  bodies  include  the  larvae  of  various 
insects  hatched  from  eggs  that  have  been  laid  in  the  nose. 
Sometimes,  as  in  the  case  of  the  larvae  of  the  various 
species  of  oestrus,  the  symptoms  are  quite  mild,  but  in 
most  cases  the  presence  of  such  bodies  leads  to  profuse 
purulent  and  sanguineous  discharge,  edema  of  the  face, 
and  rapid  destruction  of  both  the  soft  parts  and  the  bone. 
In  India  this  accident  is  observed  so  frequently  that  it 
has  received  a  special  name — "  peenash." 

The  larvae  of  other  dipterous  insects  occasionally  de- 
velop within  the  nose,  as  well  as  myriapods  (centipedes), 
earwigs,  and  termites.  Larger  creatures,  such  as  leeches, 
pin-worms,  ascaris  lumbricoides,  and  even  lizards  are  met 
among  the  "cave-dwellers"  of  the  nose.  The  symp- 
toms of  mjriasis  or  disease  due  to  the  presence  of  the 
larvae  of  flies  include,  besides  the  objectiv^e  ones  already 
described,  violent  headache  and  vertigo  going  on  to  de- 
lirium, fever,  insomnia,  and,  at  first,  violent  attacks  of 
sneezing.  Unless  the  disease  is  treated,  death  may  result 
from  extensive  destruction  of  tissue.  The  true  nature  of 
the  trouble  can  be  determined  with  certainty  only  by 


MALFORMATIONS. 


205 


recognizing  the  organisms,  either  mixed  with  the  nasal 
secretion  or  lying  free  within  the  nose.  To  bring  about 
the  death  and  elimination  of  the  larvae,  irrigation  with 
chloroform-water  has  been  found  effective.  In  the  case 
of  other  parasites,  instrumental  interference  is  usually 
necessary. 

MALFORMATIONS, 

Owing  to  the  development  of  the  oropharyngeal  cavity 
from  the  external  nasal  process  and  the  four  pairs  of 
branchial  arches,  malformations  due  to  failure  of  union 


Fig.  35.— Bifurcation  of  the  uvula. 


are  the  commonest  abnormalities  observed.  The  most 
familiar  of  these  malformations  is  the  well-known  harelip 
deformity;  similar  congenital  clefts  are,  however,  also 
observed  in  the  deeper  portions  of  the  mouth  and  in  the 


206 


MALFOBMA  TIONS, 


pharynx,  the  most  frequent  of  which,  consisting  in  bifur- 
cation of  the  uvula  (I'^ig.  35),  usually  escapes  detection 
on  account  of  the  adhesion  of  the  two  halves  of  the  struc- 
ture. In  the  nose  median  clefts  are  found,  ranging  from 
barely  perceptible  impressions  on  the  bridge  of  the  nose, 
to  the  deep  saddle-shaped  deformity.  Complete  absence 
of  the  central  portion  of  the  soft  and  hard  palates,  ex- 
posing the  entire  interior  of  the  nose  (Fig.  36),  also  occurs, 


Fig.  36.— Median  cleft-palate  in  a  child  four  years  old.  Within  the  cleft  the 
hypertrophic  pharyngeal  tonsil  is  visible  by  the  reflection  of  the  light  on  the 
prominent  portions  of  the  tissue. 


and  may  in  later  life  be  erroneously  attributed  to  syphilis 
instead  of  to  congenital  malformation. 

These  and  other  similar  median  clefts  are  due  to  failure 
of  the  supramaxillary  process  to  unite  with  the  internal 
nasal  process.  Incomplete  union  between  the  supra- 
maxillary and  external  nasal  process,  as  well  as  imperfect 
development  of  the  intermaxillary  bone,  results  in  the 
formation  of  a  lateral  cleft.     The  former  produces  the 


CLEFTS.  207 

oblique  facial  cleft ;  the  latter,  the  lateral  maxillary  and 
palatal  clefts. 

Lateral  clefts  may  be  unilateral  or  bilateral.  In  the 
first  case  there  is  a  linear  defect  to  the  side  of  the  inter- 
maxillary bone ;  in  the  latter,  the  peculiar  formation  of 
the  so-called  coccyx.  The  latter  consists  of  the  anterior 
portion  of  the  intermaxillary  bone  and  several  teeth, 
flanked  on  each  side  by  a  sagittal  cleft  running  backward 
through  the  lip  and  the  maxilla. 

Rudimentary  clefts  are  also  observed  in  the  form  of 
congenital  absence  of  a  canine  tooth,  a  lateral  notch  in 
the  upper  lip,  or  a  similar  defect  in  the  soft  or  hard  palate. 
The  small  defects  seen  in  the  palatal  arches  may  be 
attributed,  if  syphilis  can  be  excluded,  to  congenital  mal- 
formation ;  just  as  the  inversion  of  odontoblasts  in  the 
nose  or  antrum  of  Highmore  is  to  be  attributed  to  a 
failure  of  the  lateral  maxillary  cleft  to  become  closed. 
Cervical  fistulse,  either  complete — that  is,  provided 
with  an  internal  and  an  external  opening,  the  internal 
opening  being  always  in  the  region  of  the  palatal  tonsils — 
or  incomplete, — that  is,  with  only  one  opening, — are  the 
result  of  incomplete  closure  of  the  branchial  clefts.  The 
deep  dermoid  cysts  of  the  neck  and  pharynx  and  the 
pharyngeal  diverticula,  which  are  always  of  con- 
genital origin  but  may  undergo  enlargement  in  later  life, 
are  to  be  regarded  as  rudimentary  structures  of  similar 
origin. 

During  the  closure  of  embryonal  clefts  superficial  por- 
tions of  the  body  may  become  displaced  into  deeper  strata, 
and  these  islands  of  epidermal  and  epithelial  tissue,  owing 
to  the  untrammeled  growth  of  embryonal  life,  are  apt  to 
form  tumors  known  as  branchiogenetic  carcino- 
mata,  which,  on  account  of  their  deep  situation  along 
the  vessels  of  the  neck,  may  present  insuperable  obstacles 
to  extirpation. 

Peculiar  disturbances  of  an  obstructive  character  are 
not  infrequently  produced  by  excessive  development  of 
bone,  cartilage,  and  connective  tissue  in  the  upper  respi- 


208  MALFORMATIONS. 

ratory  passages.  Narrowing  of  the  mesopharynx  and 
hypopharynx  has  been  observed  as  a  result  of  marked 
prominence  of  the  bodies  of  the  second  and  third  cervical 
vertebrae,  a  condition  usually  described  somewhat  loosely 
as  lordosis  of  the  cervical  vertebral  column.  Marked 
wing-like  prominence  of  the  upper  portion  of  the  posterior 
border  of  the  vomer,  the  ala  vomeris,  sometimes  presents 
an  obstacle  to  the  extirpation  of  a  pharyngeal  tonsil,  or 
at  least  may  alarm  the  inexperienced.  Exostosis  of  the 
vomer  (see  Fig.  30,  p.  168)  and  of  the  perpendicular  plate 
of  the  ethmoid  bone  at  the  crest  of  the  septum  ;  excessive 


Fig.  37. 


prominence  of  the  pterygoid  process  with  narrowing  of 
the  choanae  (Fig.  37) ;  the  formation  of  a  membrane 
behind  the  nose  (Figs.  38,  39) ;  total  or  ])artial  bony  or 
fibrous  septa  within  the  nose,  especially  in  its  posterior 
segment ;  and,  finally,  rudimentary  adhesions  resembling 
bracelets  in  form  (Fig.  40),  and  distinguished  from  ac- 
quired adhesions  by  the  absence  of  cicatrization,  are  some 
of  the  more  important  malformations  of  this  class. 

An  anomaly  that  is  observed  more  frequently  than  any 
other  of  this  kind  consists  in  a  spine  on  the  nasal  septum, 
associated  usually  with  exostosis  of  the  crista  septi  (Fig. 


TREATMENT.  209 

34 ;  Plate  27,  Fig.  1).  The  anomaly  is  produced  by  im- 
perfect insertion  of  the  cartilage  or  bone  of  the  septum 
into  the  process  of  the  intermaxillary  bone. 

All  these  anomalies  should  be  subjected  to  treatment 
only  when  they  give  rise  to  actual  functional  disturbances 
or  other  injuries  that  require  removal  or  palliation.  Ac- 
cordingly, the  war  of  extermination  that  is  waged  by 
many  surgeons  against  spines  of  all  kinds  is  to  be  utterly 
condemned.     Nothing  less  than  interference  with  respira- 


FiG.  38.— Membrane  behind  and  covering  the  tubal  folds. 

tion  or  the  irritation  due  to  contact  with  the  inferior  tur- 
binate and  the  stagnation  of  secretion  justifies  a  recourse 
to  the  knife.  The  popularity  of  these  operations  is  respon- 
sible for  the  enormous  number  of  methods  and  instruments 
that  have  been  devised.  For  the  removal  of  large  and 
broad  excrescences  I  recommend  a  curved  sculptor's 
chisel,  with  which  the  growths  are  chipped  away  under 
inspection ;  for  moderately  large  and  small  excrescences 
the  fenestrated  knife,  illustrated  in  Fig.  41,  which  is 
drawn  over  the  bone  or  cartilage  and  makes  a  clean  cut 

14 


210 


MALFORMA  TIOSS. 


like  a  razor,  may  be  recommended.      The  treatment  of 
atresia  depends  on  the  conditions  of  the  individual  case ; 


Fig.  39.— Membrane  behind  the  right  choana  and  the  tubal  folds :  pp,  Pro- 
jecting pterygoid  process ;  u,  inferior,  m,  middle,  turbinate ;  *,  septum ;  r, 
recess  in  the  pharyngeal  tonsil. 

bone-forceps  may  be  used  to  advantage  in  these  opera- 
tions. 

An  unpleasant  feature  of  all  these  operations  is  the  ten- 
dency to  the  formation  of  postoperative  adhesions.  The 
best  way  to  avoid  them  is  to  leave  as  large  a  distance  as 


Fig.  40.— Rudimentary  adhesion. 


possible   between   the   abraded   surfaces  from   the  very 
beginning.     It  is,  therefore,  better  not  to  be  content  with 


DEVIATION  OF  THE  NASAL  SEPTUM.  211 

mere  division  of  synechiae  and  membranes,  but  to  supple- 
ment the  procedure  by  the  extirpation  of  a  portion  of  the 
foreign  growth.  After  division  with  the  galvanocautery 
adhesions  are  so  frequent  as  to  be  the  rule.  In  any  ante- 
rior synechia,  especially  between  a  septal  spine  and  the 
inferior  turbinate  (Fig.  34,  p.  199),  the  bridge  should  be 
divided  with  a  knife  or  scissors  or  chiseled  away  close  to 
the  turbinate,  and  the  basal  portion  cut  away  with  the 
fenestrated  knife.  The  opening  later  enlarges  of  its  own 
accord.  If  an  adhesion  threatens  to  form,  it  may  readily 
be  prevented  by  introducing  thin  strips  of  gauze  saturated 
with  liquid  vaselin,  which  permits  superficial  epitheliali- 


^^piifiiifcii-J 


Fig.  41.— Fenestrated  knife  (the  handle  is  shown  in  Fig.  13,  p.  52.) 


zation  to  take  place  and  are  free  from  the  disadvantage 
of  causing  a  fresh  traumatism  at  each  renewal. 

Deviation  of  the  nasal  septum  is  a  common  de- 
formity (Plate  27,  Fig.  1).  What  has  been  said  in  regard 
to  treatment  of  malformations  applies  even  more  forcibly 
to  this  condition,  which  very  rarely  justifies  operative 
intervention.  A  certain  degree  of  deviation  of  the  septum 
to  one  side  or  the  other  is  physiologic.  Even  very  marked 
deviations  are  often  observed  that  do  not  in  the  least 
trouble  the  owner,  although,  unfortunately,  they  appear 
to  trouble  the  rhinologist  a  good  deal.  They  occasion 
hardly  any  interference  with  respiration,  because  the  nar- 
rowing of  the  side  corresponding  to  the  convexity  of  the 
septum  is  compensated  by  a  corresponding  widening  oppo- 
site the  concave  surface,  and  operation  for  the  purpose  of 
relieving  the  stenosis  is  really  indicated  only  when  tumore 
or  insuperable  obstacles  to  the  escape  of  purulent  and 
other  secretions  are  to  be  removed.     In  such  cases  an 


212  HYPOPLASIA. 

operation  to  correct  the  deviation  is  justifiable,  and  the 
author  much  prefers  the  rapid  bloody  method  to  the  un- 
certain and  slow  mechanotherapcutic  procedures.  The 
operation,  for  which  many  methods  have  been  proposed, 
consists  in  the  main  of  making  an  incision  corresponding 
to  three  sides  of  a  square  on  the  bulging  portion  of  the 
septum,  leaving  the  fourth  side  intact.  The  remaining 
portion  of  bone  or  cartilage  is  then  forcibly  broken,  and 
the  protruding  mass  pushed  over  to  the  concave  side. 
The  fragments  are  then  retained  in  their  correct  position 
for  several  days  by  firmly  packing  the  nose  with  gauze. 

Complications  with  hyperplastic  processes  at  the  site  of 
the  bulging  are  quite  common  and  demand  the  removal 
of  the  thickened  tissues.  If  possible,  a  flap  of  mucous 
membrane  should  be  reflected,  the  hyperplastic  tissue  re- 
sected, and  the  flap  returned  to  its  place.  These  opera- 
tions, of  course,  require  a  rhinologic  technic  which  cannot 
be  learned  from  books. 

Two  forms  of  hypoplasia  that  occur  in  the  oropharynx 
deserve  mention  on  account  of  their  clinical  importance. 
They  are  shortness  of  the  frenum  of  the  tongue,  producing 
the  condition  known  as  tongue-tie,  which  must  be  relieved 
when  there  is  actual  interference  with  the  movement  of 
the  tongue ;  and  shortness  of  the  hard  palate,  usually 
described  as  insufficiency  of  the  velum,  so  that  when  the 
velum  is  contracted,  it  fails  to  reach  Passavant's  fold. 
The  effect  is  the  same  as  that  of  paralysis  of  the  soft 
palate — namely,  rhinolalia  aperta ;  while  failure  of  the 
glottis  to  close  the  larynx  rarely  occurs,  because  the  indi- 
vidual learns  to  adapt  himself  to  the  abnormal  condition. 


INDEX. 


Abrasions,  superficial,  55 
Abscess,  chronic  tonsillar,  142 

of  lingual  tonsil,  143 

of  palatal  tonsil,  141 

of  pharyngeal  tonsil,  142 

of  tongue  from  phlegmon,  66 

orbital,  105 

tonsillar,  141 
Accessory  struma,  178 
Actinomycosis,  132 

diagnosis  of,  133 

treatment,  133 
Adhesions  from  syphilis,  122 
Adrenalin  in  nasal  hemorrhage,  44 
Ageusia,  189 
Alveolaris,  pyorrhoea,  81 
Anesthesia  of  nose,  186 

of  pharynx,  187 
Aneurysm,  170 
Angina,  benign  fibrinous,  60 

Ludwig's,  67 
Angioma,  cavernous,  169 
Anomalies,  205 

treatment,  209 
Anosmia,  190 

prognosis,  190 
Antrum  of  Highmore,  diseases  of, 
96 
empyema  of,  96 
hydrops  of,  98 
irrigating  cannula  for,  101 


Aphthae,  chronic  recurring,  67 
Aphthous  stomatitis,  58 

ulcer,  superficial,  127 
Aprosexia,  151 
Aromatic  ageusia,  190 

parageusia,  190 
Asthma,  192 

treatment  of,  193 
Atrophic  processes,  88 

Benign  fibrinous  angina,  60 

pharyngeal  ulcer,  57 
treatment,  68 

tumors,  179 
Blood-supply  of  nose,  15 

of  oropharynx,  4 
Bone  cysts  in  middle   turbinate, 

105 
Bone-forceps,  49,  111 
Branchiogenetic  carcinomata,  207 
Burns,  200 

Cacosmia,  191 
Calculi,  salivary,  81 
Cannula,  frontal  sinus,  115 
irrigating,  for  antrum  of  High- 
more,  101 
irrigating,  for  sphenoid  sinus, 
101 
Carcinoma,  175 
branchiogenetic,  207 

213 


214 


INDEX. 


Carcinoma,  diagnosis,  176 
Cardiac  neuroses,  195 
Cartilaginous  tumors,  167 
Catarrh,  chronic  nasal,  84 
of  sphenoid  sinus,  109 
diflFuse,  and  nasal  catarrh,  differ- 
entiation, 90 
of  antrum  of  Highmore,  96 

diagnosis,  98 
simple  acute,  64 
Cavernous  angioma,  169 
Cervical  fistulie,  207 
Chemical  injuries,  199 
Congenital  neoplasms,  177 

treatment,  180 
Coughing,  paroxysmal  attacks  of, 

192,  194 
Curets,  62 

Cystic  lymphangioma,  170 
Cysts,  bone,  in -middle  turbinate, 
105 
dermoid,  178,  207 

Deformity  of  thorax,  162 
Dermoid  cysts,  178,  207 
Deviation  of  nasal  septum,  212 
Diaphragmatic  furrow,  162 
Diffuse  catarrh  and  nasal  catarrh, 
differentiation,  90 
forms  of  chronic  inflammations, 

91 

lymphangioma,  170 
Diphtheria,  60 

prognosis,  61 

treatment,  61 
Diverticula,  pharyngeal,  207 

ECCHONDROMATA,   167 

Empyema  of  antrum   of   High- 
more,  96 


Endotheliomata,  173 
Enlargement    of    lingual    tonsil, 
146 
of  palatal  tonsil,  146 
of  pharyngeal  tonsil,  147 
Enuresis,  nasal,  27,  153 
Epidemic  stomatitis,  73 
Epilepsy,  nasal,  27,  153 
Epulis,  165 
Erysipelas,  63 

treatment,  expectant,  65 
Ethmoid   cells,  chronic   suppura- 
tion of,  104 
diseases  of,  104 
Exanthemata,  acute,  70 

treatment,  73 
Extirpation  of  pharyngeal  tonsil, 
156 

Fenestrated  knife,  211 
Fibrinous  angina,  benign,  60 
Fibro-epithelioma,  165 
Fibroma,  164 

papillary,  165 
Fibromyoma,  169 
Fistulae,  cervical,  207 
Foliata,  papilla,  167 
Forceps,  bone-,  49,  111 
Foreign  bodies,  201 

consequences  of,  202 

diagnosis  of,  203 

organic,  204 

symptoms,  202 

treatment,  203 
Frontal  sinus  cannula,  115 

diseases  of,  111 

suppuration  of.  111 
diagnosis,  113 
symptoms,  113 
treatment,  114 


INDEX. 


215 


Gangrene,  69 

treatment,  70 
German  measles,  72 
Glanders,  125 

diagnosis,  126 

treatment,  126 
Glandular  tumors,  171 
Glossitis,  MoUer's,  182 
Glossodynia,  189 

treatment,  189 
Gonorrheal  infection,  59 

diagnosis,  60 
Granulation  tissue,  127 
Granulomata,  165 

Hairy  pharyngeal  polypi,  177 
Hay-fever,  199 

Hemorrhage,  nasal, adrenalin  in, 44 
Herpes,  76 

Heterologous  neoplasms,  173 
Highmore,  antrum  of,  diseases  of, 
96 
empyema  of,  96 
hydrops  of,  98 
irrigating  cannula  for,  101 
Homologous  neoplasms,  164 
Hydrops  of  antrum  of  Highmore, 

98 
Hydrorrhea,  vasomotor  nasal,  191 
Hyperesthesia,  188 
Hyperkinetic  disturbances,  185 
Hyperplasia  of  lingual  tonsil,  146 
of  lymphatic  ring,  144 
of  palatal  tonsil,  146 
of  pharyngeal  tonsil,  147 
of  tonsils,  144 
sequels  of,  162 
treatment,  154 
Hypertrophy,  lateral,  of  pharynx, 
82 


Hypesthesia  of  pharynx,  187 
Hypokinetic  disturbances,  183 
Hypoplasia  in  oropharynx,  212 

Inflammation,  acute,  of  sphe- 
noid sinus,  109 
interstitial,  63 
Inflammations,  54 
acute,  of  lymphatic  ring,  134 
chronic,  80 
of  meati,  95 
of  mouth,  80 
of  nasopharynx,  84 
of  pharynx,  81 
treatment,  117 
diffuse,  91 
exudative,  59 
superficial,  55 

treatment,  56 
symptomatic  persistent,  119 
Inflammatory  diseases  of  lymph- 
atic ring,  134 
Influenza,  74 
Injuries,  chemical,  199 
mechanical,  199 
thermic,  200 
traumatic,  197 
Irrigating  cannula  for  antrum  of 
Highmore,  101 
for  sphenoid  sinus,  101 

JtrvENiLK    sarcoma    of    naso- 
pharynx, 160 
symptoms,  161 
treatment,  161 

Knife,  fenestrated,  211 
Koplik's  spots,  71 

Lacunar  tonsillitis,  134 


216 


INDEX. 


Lacunar  tonsillitis,  complications, 
137 
pathogenesis,  133 
symptoms,  134 
treatment,  139 
Latent  meningitis,  66 
Leprosy,  129 
diagnosis,  130 
symptoms,  130 
treatment,  131 
Lingua  nigra,  167 
Lingual  tonsil,  abscess  of,  143 

hyperplasia  of,  146 
Lipomata,  167 
Lorgnette  nose,  122 
Lud wig's  angina,  67 
Lupous  infiltrate,  127 
Lymphadenoid  polypi,  167 
Lymphangioma,  cystic,  170 

diffuse,  170 
Lymphatic  nodules,  170 
tumors,  170 
treatment,  171 
Lymphosarcoma,  174 

Macroglossia,  total,  169 
Malformations,  205 

treatment  of,  209 
Malignant  papilloma,  166 

tumors,  179 
Measles,  German,  72 
Mechanical  injuries,  199 
Meningitis,  latent,  65 
Mercurial  ptyalism,  57 
Moller's  glossitis,  182 
Mouth,  anatomy  and  physiology, 
1 

chronic  inflammations  of,  80 

diseases  of,  causes,  19 
examination  in,~31 


Mouth,  diseases  of,  pathology  of, 
general,  19 
special,  54 
symptoms,  23 
treatment,  39 
Mouth-hook,  32 

Mucous    membranes,   upper,    ap- 
pearances in,  in  general 
diseases,  181 
polypi,  86 
Muscles,  diseases  of,  183 
Mycoses,  162 
Mycosis,  nasal,  163 
Myxomata,  167 

Nasal  catarrh  and  diffuse  catarrh, 
differentiation,  90 
chronic,  84 

enuresis,  27,  153 

epilepsy,  27,  153 

hj'^drorrhea,  vasomotor,  191 

mycosis,  163 

passages,  diseases  of,  93 

respiration,  mechanism  of,  16 
Nasopalatine  dyslalia,  causes  of,  7 
Nasopharynx,  diseases  of,  91 

juvenile  sarcoma  of,  160 
symptoms,  161 
treatment,  161 
Neoplasms,  164 

congenital,  177 
treatment,  180 

heterologous,  173 

homologous,  164 
Nerves,  diseases  of,  183 
Neuralgia,  188 
Neuritis,  184 
Neuroses,  cardiac,  195 

reflex,  192 
Nodules,  lymphatic,  170 


INDEX. 


217 


Noma,  70 

Nose,  anatomy  and  physiology,  1 
diseases  of,  causes,  19 
examination  in,  31 
pathology  of,  general,  19 

special,  54 
symptoms,  23 
treatment,  39 
Nuhn,  glands  of,  4 

Orbital  abscess,  105 
Organic  foreign  bodies,  204 
Osseous  tumors,  167 
Ozena,  11,  90 

Palsies,  peripheral,  184 

Papilla  foliata,  167 

Papillary  fibro-epithelioma,  165 

fibroma,  165 
Papilloma,  hard,  165 

malignant,  166 

soft,  165 
Parageusia,  189 

aromatic,  190 
Paralysis,  184 
Paresthesia,  188 

treatment,  188 
Parosmia,  190 

Paroxysmal  attacks  of  coughing, 
192,  194 
of  sneezing,  192,  194 
Peenash,  204 

Perforating  ulcer  of  septum,  84 
Periodontoma,  165 
Peripheral  palsies,  184 
Peritonsillar  suppurations,  68 

treatment,  69 
Pharyngeal  diverticula,  207 

polypi,  hairy,  177 

tumors,  180 


Pharyngeal     tumors,     treatment, 
180 

ulcer,  benign,  57 
treatment,  58 
Pharyngitis  granulosa,  82 
Pharyngomycosis  leptothricia,  163 
Phlegmon,  65 

abscess  of  tongue  from,  66 

supratonsillar,  67 
Polypi,  hairy  pharyngeal,  177 

lymphadenoid,  167 

mucous,  86 
Polypoid  tumor,  127 
Ptyalism,  mercurial,  57 
Pyorrhoea  alveolaria,  81 

Ranula,  172 

treatment,  172 
Kecurring  aphthae,  chronic,  57 
Reflex   and  remote  symptoms  of 
diseases  of  upper  respira- 
tory passages,  191 
neuroses,  192 
Reflexes,  secretory,  195 

vasomotor,  195 
Respiration,  nasal,  mechanism  of, 

16 
Retro  visceral  struma,  179 
Rotheln,  72 

Saddle-nose,  122 
Salivary  calculi,  81 
Sarcoma,  173 
juvenile,  of  nasopharynx,  160 

symptoms,  161 

treatment,  161 
Scarlet  fever,  71 

tongue,  72 
Scissors,  49 
Scleroma,  131 


218 


INDEX. 


Scleroma,  diagnosis,  132 

-treatment,  132 
Secretory  anomalies,  90 

reflexes,  195 
Sense,  special,  disturbances  of,  189 
Sensory  disturbances,  186,  191 
Septum,  perforating  ulcer  of,  84 
Sinus,  frontal  diseases  of.  111 
suppuration  of.  111 
diagnosis,  113 
symptoms,  113 
treatment,  114 
sphenoid,    acute    inflammation 
of,  109 
chronic  catarrh  of,  109 
diseases  of,  109 
irrigating  cannula  for,  101 
suppuration  of,  109 
diagnosis  of,  110 
symptoms  of,  110 
treatment  of,  111 
Small-pox,  72 
Sneezing,  paroxysmal  attacks  of, 

192,  194 
Soft  papilloma,  165 
Spasms,  1 85 

Special  sense,  disturbances  of,  189 
Sphenoid   sinus,  acute  inflamma- 
tion of,  109 
chronic  catarrh  of,  109 
diseases  of,  109 
irrigating  cannula  for,  101 
suppuration  of,  109 
diagnosis,  110 
symptoms,  110 
treatment,  111 
Spine  on  nasal  septum,  208 
Stomatitis,  73 
aphthous,  58 
epidemic,  78 


Stomatitis,  prognosis,  74 

treatment,  74 
Struma,  accessory,  178 

retro  visceral,  179 
Superficial  aphthous  ulcer,  127 
Suppuration,  chronic,  of  ethmoid 
cells,  104 
of  frontal  sinus,  111 
diagnosis,  113 
symptoms,  113 
treatment,  114 
of  sphenoid  sinus,  109 
diagnosis,  110 
symptoms,  110 
treatment.  111 
peritonsillar,  68 
treatment,  69 
Supratonsillar  phlegmon,  67 
Syphilis,  77,  119 
adhesions  from,  122 
course,  78 
diagnosis,  78,  123 
symptoms,  120 
treatment,  78,  123 

Thermic  injuries,  200 
Thorax,  deformity  of,  152 
Throat,  anatomy  and  physiology, 
1 

diseases  of,  causes,  19 

examination  in,  31 

pathology  of,  general,  19 
special,  54 

symptoms,  23 

treatment,  39 
Thrush,  162 

treatment  of,  163 
Tissue,  granulation,  127 
Tongue,  abscess  of,  from  phleg- 
moQ,  66 


INDEX. 


219 


Tongue,  scarlet  fever,  72 
Tongue-tie,  212 
Tonsil,  hyperplasia  of,  144 
sequels,  152 
treatment,  154 
lingual,  abscess  of,  143 

hyperplasia  of,  146 
palatal,  abscess  of,  141 

hyperplasia  of,  146 
pharyngeal,  abscess  of,  142 
extirpation  of,  156 
hyperplasia  of,  147 
Tonsillar  abscess,  141 

chronic,  142 
Tonsillitis,  lacunar,  134 
complications  of,  137 
pathogenesis,  134 
symptoms,  134 
treatment,  139 
Traumatic  injuries,  197 
Tuberculosis,  126 
course,  128 
diagnosis,  128 
treatment,  129 
Tumors,  benign,  179 
cartilaginous,  167 


Tumors,  glandular,  171 

lymphatic,  170 
treatment  of,  171 

malignant,  179 

osseous,  167 

pharyngeal,  180 

polypoid,  127 

treatment,  180 

vascular,  169 
Typhoid  fever,  75 

Ulcer,  benign  pharyngeal,  57 
treatment,  58 
deep,  127 

perforating,  of  septum,  84 
superficial  aphthous,  127 

Ulceration,  57 

Varicella,  72 
Vascular  tumors,  169 
Vasomotor  disturbances,  191 

nasal  hydrorrhea,  191 

reflexes,  195 

Warts,  170 
Water-cancer,  70 


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This  department  of  medicine  being  one  in  which,  from  lack  of  practical 
knowledge,  much  harm  can  be  done,  and  in  which  in  recent  years  great 
importance  has  obtained,  a  book,  accurately  portraying  the  anatomic  rela- 
tions of  the  fractured  parts,  together  with  the  diagnosis  and  treatment  of  the 
condition,  becomes  an  absolute  necessity.  This  present  work  fully  meets 
all  requirements.  As  complete  a  view  as  pnjssible  of  each  case  has  been 
presented,  thus  equipping  the  physician  for  the  manifold  appearances  that 
he  will  meet  with  in  practice.  The  author  has  brought  together  in  this  work 
a  collection  of  illustrations  unrivalled  for  accuracy  and  clearness  of  portrayal 
of  the  conditions  represented,  showing  the  visible  external  deformity,  the 
X-ray  shadow,  the  anatomic  preparation,  and  the  method  of  treatment 


They  are  Satisfactory  Substitutes  for  Clinical  Observation 


SAUNDERS'   MEDICAL   HAND-ATLASES 

Sultan  and  Coley's 
Abdominal  Hernias 


Atlas  and  Epitome  of  Abdominal  Hernias.  By  Privat- 
DOCENT  Dr.  Georg  Sultan,  of  Gottingen.  Edited,  with  addi- 
tions, by  William  B.  Coley,  M.  D.,  Clinical  Lecturer  on  Sur- 
gery, Columbia  University  (College  of  Physicians  and  Surgeons), 
New  York.  With  119  illustrations,  36  of  them  in  colors,  and 
277  pages  of  text.     Cloth,  $3.00  net. 

DEALING  WITH  THE  SURGICAL  ASPECT 

This  new  atlas  covers  one  of  the  most  important  subjects  in  the  entire 
domain  of  medical  teaching,  since  these  hernias  are  not  only  exceedingly 
common,  but  the  frequent  occurrence  of  strangulation  demands  extraordi- 
narily quick  and  energetic  surgical  intervention.  During  the  last  decade  the 
operative  side  of  this  subject  has  been  steadily  growing  in  importance,  until 
now  it  is  absolutely  essential  to  have  a  book  treating  of  its  surgical  aspect. 
This  present  atlas  does  this  to  an  admirable  degree.  The  illustrations  are 
not  only  very  numerous,  but  they  excel,  in  the  accuracy  of  the  portrayal  of 
the  conditions  represented,  those  of  any  other  work  upon  abdominal  hernias 
with  which  we  are  familiar.  The  work  will  be  found  a  worthy  exponent 
of  our  present  knowledge  of  the  subject  of  which  it  treats. 


PERSONAL  AND  PRESS  OPINIONS 


Robert  H.  M.  Dawbarn.  M.  D., 

Professor  of  Surgery  and  Surgical  Anatomy,  New  York  Polyclinic. 

"  I  have  spent  several  interested  hours  over  it  to-day,  and  shall  willingly  recommend 
it  to  my  classes  at  the  Polyclinic  College  and  elsewhere." 

Boston  Medical  iknd  Surgical  Journal 

"  For  the  general  practitioner  and  the  surgeon  it  will  be  a  very  useful  book  for  reference. 
The  book's  value  is  increased  by  the  editorial  notes  of  Dr.  Coley." 

They  have  already  appeared  in  thirteen  different  languages 


SAUNDERS'    MEDICAL   HAND- ATLASES  7 

Brtihl,  Politzer,  and 
MacCuen  Smith's  Otology 


Atlas  and  Epitome  of  Otology.  By  Gustav  Bruhl,  M.  D., 
of  Berlin,  with  the  collaboration  of  Professor  Dr.  A.  Politzer, 
of  Vienna.  Edited,  with  additions,  by  S.  MacCuen  Smith, 
M.  D.,  Clinical  Professor  of  Otology,  Jefferson  Medical  Col- 
lege, Philadelphia.  With  244  colored  figures  on  39  lithographic 
plates,  99  text-illustrations,  and  292  pages  of  text.  Cloth,  $3.00 
net. 

INCLUDING  ANATOMY  AND  PHYSIOLOGY 

This  excellent  volume  is  the  first  attempt  to  supply  in  English  an  illus- 
trated clinical  handbook  to  act  as  a  worthy  substitute  for  personal  instruction 
in  a  specialized  clinic.  This  worlc  is  both  didactic  and  clinical  in  its  teach- 
ing, the  latter  aspect  being  especially  adapted  to  the  student's  wants.  A 
special  feature  is  the  very  complete  exposition  of  the  minute  anatomy  of  the 
ear,  a  working  knowledge  of  which  is  so  essential  to  an  intelligent  concep- 
tion of  the  science  of  otology.  The  illustrations  are  beautifully  executed  in 
colors,  and  illuminate  the  text  in  a  singularly  lucid  manner,  portraying  patho- 
logic changes  with  such  striking  exactness  that  the  student  should  receive  a 
deeper  and  more  lasting  impression  than  the  most  elaborate  description 
could  produce.  Further,  the  association  of  Professor  Politzer  in  the  prepa- 
ration of  the  work,  and  the  use  of  so  many  valuable  specimens  from  his 
notably  rich  collection  especially  enhance  the  value  of  the  work.  The  text 
contains  everything  of  importance  in  the  elementary  study  of  otolog;y. 


PERSONAL  AND  PRESS  OPINIONS 


Clarence  J.  Blake.  M.  D.. 

Professor  of  Otology,  Harvard  University  Medical  School,  Boston. 
"  The  most  complete  work  of  its  kind  as  yet  published,  and  one  commending  itself  to 
both  the  student  and  teacher  in  the  character  and  scope  of  its  illustrations." 

Boston  Medical  and  Surgical  Journal 

"Contains  what  is  probably  the  best  collection  of  colored  plates  of  the  ear,  both  of 
normal  and  pathological  conditions,  of  any  hand-book  published  in  the  English  language. 
In  addition  to  this  the  text  is  presented  in  an  unusually  clear  and  direct  manner." 

They  are  offered  at  a  price  heretofore  unapproached  in  cheapness 


{  SAUNDERS'    MEDICAL   HAND-ATLASES 

Lehmann,  Neumann,  and 
Weaver's  Bacteriology 


Atlas  and  Epitome  of  Bacteriology  :  including  a  Text- 
Book  OF  Special  Bacteriologic  Diagnosis.  By  Prof.  Dr. 
K.  B.  Lehmann  and  Dr.  R.  O.  Neumann,  of  Wiirzburg.  From 
the  Second  Revised  and  Enlarged  German  Edition.  Edited, 
with  additions,  by  G.  H.  Weaver,  M.  D.,  Assistant  Professor 
of  Pathology  and  Bacteriology,  Rush  Medical  College,  Chicago. 
In  two  parts.  Part  I. — 632  colored  figures  on  69  lithographic 
plates.  Part  II. — 511  pages  of  text,  illustrated.  Per  part: 
Cloth,  $2.50  net. 

INCLUDING  SPECIAL  BACTERIOLOGIC  DIAGNOSIS 

This  work  furnishes  a  survey  of  the  properties  of  bacteria,  together  with 
the  causes  of  disease,  disposition,  and  immunity,  reference  being  constantly 
made  to  an  appendix  of  bacteriologic  technic.  The  special  part  gives  a 
complete  description  of  the  important  varieties,  the  less  important  ones  being 
mentioned  when  worthy  of  notice.  The  lithographic  plates,  as  in  all  this 
series,  are  accurate  representations  of  the  conditions  as  actually  seen,  and 
this  collection,  if  anything,  is  more  handsome  than  any  of  its  predecessors. 
As  an  aid  in  original  investigation  the  work  is  invaluable. 


OPINIONS  or  THE  MEDICAL  PRESS 


American  Journal  of  the  Medical  Sciences 

"  Practically  all  the  important  organisms  are  represented,  and  in  such  a  variety  of 
forms  and  cultures  that  any  other  atlas  would  rarely  be  needed  in  the  ordinary  hospital 
laboratory." 

The  Lancet,  London 

"  We  have  found  the  work  a  more  trustworthy  guide  for  the  recognition  of  unfamiliar 
species  than  any  with  which  we  are  acquainted." 

There  have  been  82,000  copies  imported  since  publication 


SAUNDERS'    MEDICAL   HAND-ATLASES 


Zuckerkandl  and  DaCosta's 
Operative  Surgery 

Second  Edition,  Revised  and  Greatly  Enlarged 


Atlas  and  Epitome  of  Operative  Surgery.     By  Dr.  O. 

Zuckerkandl,  of  Vienna.  Edited,  with  additions,  by  J.  Chal- 
mers DaCosta,  M.  D.,  Professor  of  the  Principles  of  Surgery 
and  Clinical  Surgery,  Jefferson  Medical  College,  Philadelphia. 
With  40  colored  plates,  278  text-cuts,  and  410  pages  of  text. 
Cloth,  $3.50  net. 

ADOPTED  BY  THE  U.  S.  ARMY 

In  this  new  edition  the  work  has  been  brought  precisely  down  to  date. 
The  revision  has  not  been  casual,  but  thorough  and  exhaustive,  the  entire 
text  having  been  subjected  to  a  careful  scrutiny,  and  many  improvements  and 
additions  made.  A  number  of  chapters  have  been  practically  rewritten,  and 
of  the  newer  operations,  all  those  of  special  value  have  been  described.  The 
number  of  illustrations  has  also  been  materially  increased.  Sixteen  valuable 
lithographic  plates  in  colors  and  sixty-one  text-figures  have  been  added,  thus 
greatly  enhancing  the  value  of  the  work.  There  is  no  doubt  that  the  volume 
in  its  new  edition  will  still  maintain  its  leading  position  as  a  substitute  for 
clinical  instruction. 


OPINIONS  OF  THE  MEDICAL  PRESS 


Philadelphia  MedictJ  Journal 

"  The  names  of  Zuckerkandl  and  DaCosta,  the  fact  that  the  book  has  been  translated 
into  13  different  languages,  together  with  the  knowledge  that  it  is  used  in  the  United  States 
Army  and  Navy,  would  be  sufficient  recommendation  for  most  of  us." 

Munchener  Medicinische  Wochenschrift 

"  We  know  of  no  other  work  that  combines  such  a  wealth  of  beautiful  illustrations  with 
clearness  and  conciseness  of  language,  that  is  so  entirely  abreast  of  the  latest  achievements, 
and  so  useful  both  for  the  beginner  and  for  one  who  wishes  to  increase  his  knowledge  of 
operative  surgery." 

E^ch  volume  is  edited,  with  additions,  by  a  leading  specialist 


lo  SAUNDERS'    MEDICAL   HAND-ATLASES 

Dtirck  and  Hektoen's 
Special  Patholo£(ic  Histolog^y 


Atlas  and   Epitome  of   Special   Pathologic  Histology. 

By  Dr.  H.  Durck,  of  Munich.  Edited,  with  additions,  by 
LuDviG  Hektoen,  M.  D.,  Professor  of  Pathology,  Rush  Medi- 
cal College,  Chicago.  In  Two  Parts.  Part  I. — Circulatory, 
Respiratory,  and  Gastro-intestinal  Tracts.  120  colored  figures 
on  62  plates,  and  158  pages  of  text.  Part  II. — Liver,  Urinary 
and  Sexual  Organs,  Nervous  System,  Skin,  Muscles,  and  Bones. 
123  colored  figures  on  60  plates,  and  192  pages  of  text.  Per 
part :   Cloth,  $3.00  net. 

A  RARE  COLLECTION  OF  BEAUTIFUL  PLATES 

The  colored  lithographs  of  this  volume  are  beautifully  reproduced,  and 
are  extremely  accurate  representations  of  the  microscopic  changes  produced 
by  disease.  The  great  value  of  these  plates  is  that  they  represent  in  the 
exact  colors  the  effect  of  the  stains,  which  is  of  such  great  importance  for 
the  differentiation  of  tissue.  The  text  portion  of  the  book  is  admirable,  and, 
while  brief,  it  is  entirely  satisfactory  in  that  the  leading  facts  are  stated,  and 
so  stated  that  the  reader  feels  he  has  grasped  the  subject  extensively.  The 
work  is  modern  and  scientific,  and  altogether  forms  a  concise  and  systematic 
view  of  pathologic  knowledge. 


PERSONAL  OPINIONS 


WUliam  H.  Welch.  M.  D.. 

Professor  of  Piithology,  Johns  Hopkins  University,  Baltimore. 

"  I  consider  Diirck's  '  Atlas  of  Special  Pathologic  Histology,'  edited  by  Hektoen,  a  very 
useful  book  for  students  and  others.     The  plates  are  admirable." 

Fr&nk  B.  Mallory.  M.  D., 

Assistant  Professor  of  Pathology ,  Harvard  University  Medical  School,  Boston. 
"  The  information  is  presented  in  a  very  compact  form ;  it  is  carefully  arranged,  briefly 
and  clearly  stated,  and  almost  always  represents  our  latest  knowledge  of  the  subject." 

They  represent  the  best  artistic  and  professional  talent 


SAUNDERS'    MEDICAL   HAND-ATLASES 

Haab  and  deSchweinitz's 
Ophthalmoscopy 


Atlas  and  Epitome  of  Ophthalmoscopy  and  Ophthal- 
moscopic Diagnosis.  By  Dr.  O.  Haab,  of  Zurich.  Fro7n  the 
Third  Revised  and  Enlarged  Gertnan  Edition.  Edited,  with 
additions,  by  G.  E.  deSchweinitz,  M.  D.,  Professor  of  Oph- 
thalmology, University  of  Pennsylvania.  With  152  colored 
lithographic  illustrations;  85  pages  of  text.     Cloth,  $3.00  net. 

Not  only  is  the  student  made  acquainted  with  carefully  prepared  oph- 
thalmoscopic drawings  done  into  well-executed  lithographs  of  the  most 
important  fundus  changes,  but,  in  many  instances,  plates  of  the  microscopic 
lesions  are  added.      It  furnishes  a  manual  of  the  greatest  possible  service. 

The  Lancet.  London 

"  We  recommend  it  as  a  work  that  should  be  in  the  ophthalmic  wards  or  in  the  library 
of  every  hospital  into  which  ophthalmic  cases  are  received." 

Haab  and  deSchweinitz's 
External  Diseases  of  Eye 


Atlas  and  Epitome  of  External  Diseases  of  the  Eye. 

By  Dr.  O.  Haab,  of  Zurich.  Edited,  with  additions,  by  G.  E. 
deSchweinitz,  M.  D.,  Professor  of  Ophthalmology,  University 
of  Pennsylvania.  With  76  colored  illustrations  on  40  litho- 
graphic plates  and  228  pages  of  text.     Cloth,  1^3.00  net. 

This  new  work  of  the  distinguished  Zurich  ophthalmologist  is  destined 
to  become  a  valuable  handbook  in  the  library  of  every  practising  physician. 
The  conditions  attending  diseases  of  the  external  eye  have  probably  never 
been  more  clearly  and  comprehensively  expounded  than  in  the  forelying 
work,  in  which  the  pictorial  most  happily  supplements  the  verbal  description. 

The  Medical  Record,  New  York 

"  The  work  is  excellently  suited  to  the  student  of  ophthalmology  and  to  the  practising 
physician.     It  cannot  fail  to  attain  a  well-deserved  popularity." 


They  aie  convenient  in  size  and  uniformly  botmd 


12  SAUNDERS'    MEDICAL   HAND-ATLASES 

Schaffer  and  Edgar's 
Labor  anS  Operative  Obstetrics 


Atlas  and  Epitome  of  Labor  and  Operative  Obstetrics. 

By  Dr.  O,  Schaffer,  of  Heidelberg.  From  the  Fifth  Revised 
and  Enlarged  German  Edition.  Edited,  with  additions,  by 
J.  Clifton  Edgar,  M.  D.,  Professor  of  Obstetrics  and  Clinical 
Midwifery,  Cornell  University  Medical  School.  14  lithographic 
plates  in  colors ;   1 39  other  cuts  ;   1 1 1  pages  of  text.     ^2.00  net. 

The  book  presents  the  act  of  parturition  and  the  various  obstetric  opera- 
tions in  a  series  of  easily  understood  illustrations.  These  are  accompanied 
by  a  text  that  treats  the  subject  from  a  practical  standpoint. 

Dublin  Journal  of  Medical  Science,  Dublin 

"  One  fault  Professor  SchaflTer's  Atlases  possess.  Their  name,  and  the  extent  and 
number  of  the  illustrations,  are  apt  to  lead  one  to  suppose  that  they  are  merely  '  atlases,' 
■whereas  the  truth  really  is  they  are  also  concise  and  modern  epitomes  of  obstetrics." 

Schaffer  £^  Edg^ar's  Obstetric 
Dia£(nosis  and  Treatment 


Atlas  and  Epitome  of  Obstetric  Diagnosis  and  Treat- 
ment. By  Dr.  O.  Schaffer,  of  Heidelberg.  Fro7n  the  Sec- 
ond Revised  Ger?tian  Edition.  Edited,  with  additions,  by  J. 
Clifton  Edgar,  M.  D.,  Professor  of  Obstetrics  and  Clinical 
Midwifery,  Cornell  University  Medical  School.  122  colored  fig- 
ures on  56  plates;  38  other  cuts;  315  pages  of  text.     $3.00  net. 

Tiiis  book  treats  particularly  of  obstetric  operations,  and,  besides  the 
wealth  of  beautiful  lithographic  illustrations,  contains  an  extensive  text  of 
great  value.     This  text  deals  with  the  practical,  clinical  side  of  the  subject. 

New  York  Medical  Journal 

"  The  illustrations  are  admirably  executed,  as  they  are  in  all  of  these  atlases,  and  the 
text  can  safely  be  commended,  not  only  as  elucidatory  of  the  plates,  but  as  expounding  the 
scientific  midwifery  of  to-day." 

These  are  the  famous  "  Lehmann  medicinische  Handatlanten  " 


SAUXDEA'S'    MEDICAL    HAND-ATLASES  13 


Mracek   and  Stelwag'on's 
Skin 

Atlas  and  Epitome  of  Diseases  of  the  Skin.  By  Prof, 
Dr.  Franz  Mracek,  of  Vienna.  Edited,  with  additions,  by 
Henry  W.  Stelwagon,  M.  D.,  Clinical  Professor  of  Derma- 
tology, Jefferson  Medical  College,  Philadelphia.  With  63  colored 
plates,  39  half-tone  illustrations,  and  200  pages  of  text.  Cloth, 
$3.50  net. 

This  volume,  the  outcome  of  years  of  scientific  and  artistic  work,  con- 
tains, together  with  colored  plates  of  unusual  beauty,  numerous  illustrations 
in  black,  and  a  text  comprehending  the  entire  field  of  dermatology.  The 
illustrations  are  all  original  and  prepared  from  actual  cases  in  Mracek' s  clinic. 

American  Jotimal  of  the  Medical  Sciences 

"  Ihe  advantages  which  we  see  in  this  book  and  which  recommend  it  to  our  minds  arei 
First,  its  handiness;  secondly,  the  plates,  which  are  excellent  as  regards  drawing,  color, 
and  the  diagnostic  points  which  they  bring  out.     We  most  heartily  recommend  it." 

Mracek  and  Bang^'s 
Syphilis  and  Venereal  Diseases 

Atlas  and  Epitome  of  Syphilis  and  the  Venereal  Dis- 
eases. By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited,  with 
additions,  by  L.  Bolton  Bangs,  M.  D.,  Professor  of  Genito- 
urinary Surgery,  University  and  Bellevue  Hospital  Medical 
College,  New  York.  With  71  colored  plates  and  122  pages 
of  text.     Cloth,  S3. 50  net. 

According  to  the  unanimous  opinion  of  numerous  authorities,  to  whom 
the  original  illustrations  of  this  book  were  presented,  they  surpass  in  beauty 
anything  of  the  kind  that  has  been  produced  in  this  field,  not  only  in  Ger- 
many, but  throughout  the  literature  of  the  world. 

Robert  L.  Dickinson,  M.  D., 

Art  Editor  of  "  The  American  Text-Book  0/  Obstetrics." 

"  The  book  that  appeals  instantly  to  me  for  the  strikingly  successful,  valuable,  and 

f-aphic  character  of  its  illustrations  is  the  '  Atlas  of  Syphilis  and  the  Venereal  Diseases.' 
know  of  nothing  in  this  country  that  can  compare  with  it." 

The  lithographs,  all  made  in  Germany,  are  unrivalled 


14  SAUNDERS'    MEDICAL    HAND-ATLASES 

Jakob  and  Fisher's 
Nervous  System  &  its  Diseases 

Atlas  and  Epitome  of  the  Nervous  System  and  its  Dis- 
eases. By  Professor  Dr.  Chr.  Jakob,  of  Erlangen.  From 
the  Second  Revised  German  Edition.  Edited,  with  additions, 
by  Edward  D.  Fisher,  M.  D.,  Professor  of  Diseases  of  the  Ner- 
vous System,  University  and  Bellevue  Hospital  Medical  College, 
New  York.     With  83  plates  and  copious  text.     Cloth,  $3.50  net. 

The  matter  is  divided  into  Anatomy,  Pathology,  and  Description  of  Dis- 
eases of  the  Nervous  System.  The  plates  illustrate  these  divisions  most 
completely  ;  especially  is  this  so  in  regard  to  pathology.  The  exact  site  and 
character  of  the  lesion  are  portrayed  in  such  a  way  that  they  cannot  fail  to 
impress  themselves  on  the  memory  of  the  reader. 

Philadelphia  Medical  Journal 

"  We  know  of  no  one  work  of  anything  like  equal  size  which  covers  this  important  and 
complicated  field  with  the  clearness  and  scientific  fidelity  of  this  hand-atlas." 

Shaffer  and  Norris' 
Gynecology 

Atlas  and  Epitome  of  Gynecology.  By  Dr.  O.  Shaffer, 
of  Heidelberg.  From  the  Second  Revised  and  Enlarged  German 
Edition.  Edited,  with  additions,  by  Richard  C.  Norris,  A.  M., 
M.  D.,  Gynecologist  to  Methodist-Episcopal  and  Philadelphia 
Hospitals.  With  207  colored  figures  on  90  plates,  65  text-cuts, 
and  308  pages  of  text.     Cloth,  $3.50  net. 

The  value  of  this  atlas  will  be  found  not  only  in  the  concise  explanatory 
text,  but  especially  in  the  illustrations.  The  large  number  of  colored  plates, 
reproducing  the  appearance  of  fresh  specimens,  will  give  the  student  a  knowl- 
edge of  the  changes  induced  by  disease  that  cannot  be  obtained  from  mere 
description. 

Bulletin  of  Johns  Hopkins  Hospital,  Baltimore 

"  The  book  contains  much  valuable  material.  Rarely  have  we  seen  such  a  valuable 
collection  of  gynecological  plates." 

These  books  are  next  best  to  actual  clinical  work 


SAUNDERS'    MEDICAL   HAND-ATLASES      .  15 

Hofmann  and  Peterson's 
Legal  Medicine 


Atlas  of  Legal  Medicine.  By  Dr.  E.  von  Hofmann,  of 
Vienna.  Edited  by  Frederick  Peterson,  M.  D.,  Chief  of 
Clinic,  Nervous  Department,  College  of  Physicians  and  Sur- 
geons, New  York.  With  120  colored  figures  on  56  plates  and 
193  half-tone  illustrations.      Cloth,  $3.50  net. 

By  reason  of  the  wealth  of  illustrations  and  the  fidelity  of  the  colored 
plates,  the  book  supplements  all  the  text-books  on  the  subject.  More- 
over, it  furnishes  to  every  physician,  student,  and  lawyer  a  veritable  treasure- 
house  of  information. 

The  Practitioner,  London 

"  The  illustrations  appear  to  be  the  best  that  have  ever  been  published  in  connection 
•with  this  department  of  medicine,  and  they  cannot  fail  to  be  useful  alike  to  the  medical 
jurist  and  to  the  student  of  forensic  medicine." 

Golebiewski  and  Bailey's 
Accident  Diseases 


Atlas  and  Epitome  of  Diseases  Caused  by  Accidents. 

By  Dr.  Ed.  Golebiewski,  of  Berlin.  Edited,  with  additions, 
by  Pearce  Bailey,  M.  D.,  Attending  Physician  to  the  Alms- 
house and  Incurable  Hospitals,  New  York.  With  71  colored 
illustrations  on  40  plates,  143  text-illustrations,  and  549  pages 
of  text.     Cloth,  ^4.00  net. 

This  work  contains  a  full  and  scientific  treatment  of  the  subject  of  acci- 
dent injury  ;  the  functional  disability  caused  thereby  ;  the  medicolegal  ques- 
tions involved,  and  the  amount  of  indemnity  justified  in  given  cases. 

Medical  Examiner  and  Practitioner 

"  It  is  a  useful  addition  to  life-insurance  libraries,  for  lawyers,  physicians,  and  for  every 
one  who  is  brought  in  contact  with  the  treatment  or  consideration  of  accidents  or  diseases 
growing  out  of  them,  or  legal  complications  flowing  from  them." 

The  "Atlas  of  Operative  Surgery"  has  been  adopted  by  U.  S.  Army 


i6  SAUNDERS'    MEDICAL   I/AND- ATLASES 

Jakob  and  Eshner's 
Internal  Medicine  &  Diag'nosis 

Atlas  and  Epitome  of  Internal  Medicine  and  Clinical 
Diagnosis.  By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited,  with 
additions,  by  Augustus  A.  Eshner,  M.  D.,  Professor  of  Clin- 
ical Medicine  in  the  Philadelphia  Polyclinic.  With  182  colored 
figures  on  68  plates,  64  illustrations  in  black  and  white,  and 
259  pages  of  text.     Cloth,  $3.00  net. 

In  addition  to  an  admirable  atlas  of  clinical  microscopy,  this  volume 
describes  the  physical  signs  of  all  internal  diseases  in  an  instructive  manner 
by  means  of  fifty  colored  schematic  diagrams.  As  a  means  of  instruction 
its  value  is  very  great ;  as  a  reference  handbook  it  is  admirable. 

British  Medical  Journal 

"  Dr.  Jakob's  work  deserves  nothing  but  praise.  The  information  is  accurate  and  up 
to  present-day  requirements." 

Grunwald  and  Grayson's 
Diseases  of  the  Larynx 


Atlas  and  Epitome  of  Diseases  of  the  Larynx.     By  Dr. 

L.  Grunwald,  of  Munich.  Edited,  with  additions,  by  Charles 
P.  Grayson,  M.  D.,  Physician-in-Charge,  Throat  and  Nose 
Department,  Hospital  of  the  University  of  Pennsylvania.  With 
107  colored  figures  on  44  plates,  25  text-illustrations,  and  103 
pages  of  text.     Cloth,  $2.50  net. 

This  atlas  exemplifies  a  happy  blending  of  the  didactic  and  clinical,  such 
as  is  not  to  be  found  in  any  other  volume  ujxjn  this  subject.  The  author 
has  given  special  attention  to  the  clinical  portion  of  the  work,  the  sections 
on  diagnosis  and  treatment  being  particularly  full. 

The  Medical  Record,  New  York 

"  This  is  a  good  work  of  reference,  being  both  practical  and  concise.  .  .  .  It  is  a  vain* 
able  addition  to  existing  laryngeal  text-books." 

For  "  Special  Offer  "  regarding  these  atlases  see  page  I 


Date  Due 

PRINTED  IN  U.S..             CAT.    NO.    24    161                m 

SAUNDERS^  MEDICAL  HAND-ATLASFS 

Atlas  and  Epitome  of  Labor  and 

Heidelberg.  From  the  Ft/tk  Rm 
C  Edgar,  M.  D.,  Professor  of  Obi 
Medical  School.  W  ith  14  lithograph 
"  A  careful  study  of  the  plates  and 
fMx^ne,Xi<:^."— Buffalo  Medical  J,mr\ 
AqandEpitomeofObstetncalDU^^^^ 

of  Heidelberg.     From  the  U.ona   ''^''f,'"  ''"^  ^^  Obftetrics  and  Clinical  Midwifery. 


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